Surgical versus endoscopic treatment of bile duct stones

[Modern minimally invasive technologies for the treatment of cholelithiasis]

Surgical community has not yet reached any consensus on the adequate treatment of gallstone disease with combined stones of the gallbladder and bile ducts. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic papillosphincterotomy (EPST) followed by laparoscopic cholecystectomy (LCE) have been considered the optimal treatment method for the past thirty years. Thanks to improvement of technologies and experience in laparoscopic surgery, many centers in the world offer simultaneous treatment of cholecystocholedocholithiasis, i.e. LCE and laparoscopic choledocholithotomy. Transcystical and transcholedochal extraction of calculi from the common bile duct is the most common. Intraoperative cholangiography and choledochoscopy are used to assess extraction of calculi while T-shaped drainage, biliary stent and primary suture of common bile duct are used to complete choledocholithotomy. Laparoscopic choledocholithotomy is associated with certain difficulties, requires some experience in choledochoscopy and intracorporeal suturing of common bile duct. There are many unresolved issues regarding the choice of laparoscopic choledocholithotomy technique depending on the number and dimensions of stones, diameter of cystic duct and common bile duct. The authors analyze literature data on the role of modern minimally invasive interventions in the treatment of gallstone disease.

Comparison of one-stage treatment versus two-stage treatment for the management of patients with common bile duct stones: A meta-analysis

Background

Cholelithiasis is a frequently occurring disease in clinic. Due to changes in people's living environments, dietary habits and the aging population, cholelithiasis incidence is increasing. Currently, laparoscopic cholecystectomy (LC) is the preferred treatment for gallbladder stones, but the surgical method for patients with choledocholithiasis is controversial. An endoscopic retrograde cholangiopancreatography (pERCP) is performed preoperatively, followed by LC as the general treatment method. However, pERCP still has some disadvantages, such as prolonged hospital stay, increased incidence of postoperative pancreatitis, and increased duration of anesthesia. Therefore, intraoperative endoscopic retrograde cholangiopancreatography (iERCP) is proposed.

Objective

To compare the efficacy and safety of one-stage treatment and two-stage treatment for the management of patients with cholecystolithiasis and choledocholithiasis.

Search strategy

PubMed, Embase, Web of Science, and Cochrane databases were searched through October 2022. The search terms include cholangiolithiasis/bile duct stones/calculi, endoscopic retrograde cholangiopancreatography/ERCP, endoscopic sphincterotomy/EST, laparoendoscopic rendezvous (LERV), and laparoscopic cholecystectomy/LC.

Selection criteria

For the treatment of patients with cholecystolithiasis and choledocholithiasis in adults, randomized controlled trials (RCTs) comparing LC with iERCP vs. pERCP followed by LC were conducted.

Data collection and analysis

Data extraction and quality assessment were performed by two reviewers. We used Revman version 5.3 to analyze the collected data. The trials were grouped according to the evaluation results such as the overall mortality rate, overall morbidity rate, clearance rate of choledocholithiasis, incidence of pancreatitis, the length of hospitalization, and the length of operation.

Results

9 RCTs (950 participants) were included in this meta-analyses. The overall morbidity rate in LC + iERCP group is lower than that in LC + pERCP group (RR: 0.57, 95% CI = 0.41-0.79, p = 0.0008). The clearance rate of choledocholithiasis in LC + iERCP group was almost the same as that in LC + pERCP group (RR: 1.03, 95% CI = 0.98-1.08, p = 0.28). The incidence of pancreatitis in LC + iERCP group is lower than that in LC + pERCP group (RR: 0.29, 95% CI = 0.13-0.67, p = 0.004). The length of operation of the LC + iERCP group seems to be similar to that of the LC + pERCP group (MD: 16.63 95% CI = -5.98-39.24, p = 0.15). LC + iERCP group has a shorter length of hospitalization than that in LC + pERCP group (MD: -2.68 95% CI = -3.39--1.96, p < 0.00001). LC + iERCP group has lower postoperative second ERCP rate than that in LC + pERCP group (RR: 0.13, 95% CI = 0.03-0.57, p = 0.006).

Conclusion

Our study suggest that LC + iERCP may be a better option than LC + pERCP in the management of patients with both cholecystolithiasis and choledocholithiasis. This procedure can reduce the overall incidence of postoperative complications, especially the occurrence of postoperative pancreatitis. It could shorten the length of hospital stay, reduce postoperative second ERCP rate.

One hundred most cited articles related to Endoscopic retrograde cholangiopancreatography: A bibliometric analysis

Background

Endoscopic retrograde cholangiopancreatography (ERCP) has developed over the past few decades into a reliable technology for diagnostic and therapeutic purposes. Through a bibliometric analysis, this research attempted to evaluate the characteristics of the top 100 articles on ERCP that had the most citations.

Methods

We extracted pertinent publications from the Web of Science Core Collection (WoSCC) on July 9, 2022. The top 100 ERCP articles with the most citations were identified and analyzed. The following data were extracted: publication year, country/region, organization, total citation times, annual citation times, research type and research field, etc. To implement the network’s visual analysis, a bibliographic coupling network based on keywords was built using the VOSviewer 1.6.17 program.

Results

The journal with the most publications were GASTROINTESTINAL ENDOSCOPY, with 45 articles. Most of the top 100 articles came from the United States (n = 47) and Italy (n = 14). Indiana University and the University of Amsterdam were among the most important institutions in ERCP research. ML Freeman of the University of Minnesota contributed the highest number (n = 9) and the most highly cited paper. The age of the paper and article type is closely related to citation frequency. Of the 100 most-cited articles, clinical application in the field of ERCP has focused on three aspects: diagnosis, treatment, and complications. Clinical use of ERCP has shifted from diagnosis to treatment. Post-ERCP pancreatitis is the focus of attention, and the clinical application of technically complex therapeutic ERCP is the future development trend.

Conclusion

This study lists the most influential articles in ERCP by exposing the current state of the field, and showing the evolution of research trends to provide perspective for the future development of ERCP.

Primary Recurrent Common Bile Duct Stones: Timing of Surgical Intervention

Cholelithiasis (gallstones) is a very common medical problem worldwide, with 5-30% of patients demonstrating a combined condition of cholelithiasis and choledocholithiasis (common bile duct stones (CBDS)). CBDS are usually classified as primary or secondary stones. Primary CBDS are defined as stones detected 2 years or more following cholecystectomy, while secondary stones, the most common type, usually migrate from the gallbladder to the bile ducts. Recurrent CBDS are defined as stones detected 6 months or more following endoscopic retrograde cholangiopancreatography (ERCP) with complete duct clearance. Although ERCP with endoscopic sphincterotomy has emerged as the main therapeutic option for CBDS, with up to 95% bile duct clearance rate, up to 25% of said patients develop recurrent bile duct stones. Thus far, several issues related to recurrent CBDS are still unclear and questions regarding this specific pathology have no precise answers: how many trials of ERCP and endoscopic sphincterotomy should be attempted before referring the patient for surgical management? Is there an association between risk factors and early surgical intervention? Thus, currently, there is no worldwide scientific-based consensus regarding the best management of this specific group of patients. The main issue for this article is to review the relevant English literature and find out the main high risk factors for recurrent CBDS, and form a diagnostic and treatment plan, hence, identifying the subgroup of patients that will benefit from early surgical management, preventing further ERCP-associated complications.

Surgical Treatment for Choledocholithiasis Following Repeated Failed Endoscopic Retrograde Cholangiopancreatography

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is the first line treatment for choledocholithiasis. In many occasions, several attempts of ERCP are performed until failure is declared and surgical treatment is applied, in many times following procedure-related complications. We present the results of surgical management of patients with choledocholithiasis following repeated failures of ERCP due to impaction of multiple large stones.

METHODS

Patients that underwent surgical treatment for choledocholithiasis following repeated ERCP attempts between January 2006 and December 2018 were retrospectively assessed. Post-ERCP complications were evaluated and the surgical approach, technique, and outcomes were assessed.

RESULTS

One hundred and two patients were operated on for choledocholithiasis following repeated failed ERCP. All the patients had at least 2 failed attempts (mean = 3.2 ± 1.7), and 25 (23.5%) suffered major ERCP-related complications. Following choledochotomy and stone extraction, bilioenteric anastomosis was done in the vast majority of patients (90.2%), most commonly choledochoduodenostomy (62%). Thirty-eight (37%) patients had minimally invasive procedure (laparoscopic n = 26, robotic assisted n = 12). Major post-operative complications (Clavien-Dindo ≥ 3) occurred in 24 patients (23.5%). Nine patients (8.8%) were re-operated and 10 (9.8%) were readmitted within 30 days from surgery. Three patients died within 30 days from surgery. Older patients had significantly more ERCP attempts and suffered higher post-operative mortality. During a median follow-up of 70 months, the only biliary complication was an anastomotic stricture in one patient.

CONCLUSION

Surgery for CBDS after failure of ERCP is safe and provides a highly effective long-term solution.

The Possible Association of Non-Alcoholic Fatty Liver Disease with Acute Cholangitis: A Retrospective Multicenter Cohort Study

Non-alcoholic fatty liver disease (NAFLD) is increasingly encountered. It is associated with several comorbid diseases. However, its association with infectious biliary diseases is still unknown. Aims: We aimed to assess whether NAFLD is a risk factor for the development of acute cholangitis among patients with common bile duct (CBD) stones. Methods: We performed a retrospective study, including all patients with a documented diagnosis of CBD stone that had available data on the presence or absence of NAFLD. Descriptive analysis using univariate and multivariate models was used to assess whether an association existed between NAFLD and acute cholangitis. Results: We included 811 patients. Of them, 161 patients presented with acute cholangitis, vs. 650 patients who presented with symptomatic CBD stone without cholangitis. NAFLD was significantly more common in the cholangitis group compared to the non-cholangitis group (15.5% vs. 8.3%, p = 0.01). In univariate analysis, age (Odds ratio (OR) 1.04, p < 0.0001), male gender (OR 1.47, p = 0.03), hypertension (OR 1.81, p = 0.0008), hyperlipidemia (OR 1.59, p = 0.01), and NAFLD (OR 2.04, p = 0.006) were significantly associated with acute cholangitis. In multivariate analysis, NAFLD kept its association with acute cholangitis irrespective of age (OR 2.15, p = 0.005). Conclusions: NALFD showed a significant association with acute cholangitis among patients with a CBD stone. Clinicians should encourage treatment of NAFLD in general, and especially in the setting of gallstone disease.

Laparoscopic common bile duct exploration after failed endoscopic retrograde cholangio-pancreatography: Our patient series over a period of 10 years

Aim:

Laparoscopic CBD exploration (LCBDE) for Common bile duct (CBD) stones with laparoscopic cholecystectomy (LC) is an alternative to open CBD exploration, in patients with failed endoscopic retrograde cholangio-pancreatography (ERCP). It is being performed at few centres with adequate surgical expertise. Herein, we present our experience of LCBDE with LC over a period of 10 years.

Patients and Methods:

A retrospective analysis of prospectively recorded data of 121 consecutive patients was performed from February 2010 to November 2019, who underwent LC and LCBDE by choledochotomy in a single surgical unit. These included all patients with failed pre-operative ERCP.

Results:

Out of 121 patients, LCBDE successfully cleared the CBD in 118, and three patients were converted to open surgery. All these patients underwent choledochotomy for adequate exploration of CBD. T-tube closure of CBD was performed in 103 patients and removed after a mean of 14.6 ± 2.4 days. Primary closure was performed in 15 patients. The mean hospital stay post-procedure was 3.4 ± 0.7 days. Complete ductal clearance was achieved in 115 patients, and residual stone fragments reported in three patients were removed by ERCP. None of the patients experienced biliary peritonitis, biliary fistula, pancreatitis or cholangitis. There was no 30-day mortality and no recurrent stones reported with a mean follow-up of 12.4 ± 3.9 months.

Conclusion:

With adequate surgical expertise, LCBDE is a feasible alternative to open surgery for CBD stones after failed ERCP with early recovery and low morbidity.

Clinical Impact of Preoperative Relief of Jaundice Following Endoscopic Retrograde Cholangiopancreatography on Determining Optimal Timing of Laparoscopic Cholecystectomy in Patients with Cholangitis

Background: About 10% of patients with gallbladder (GB) stones also have concurrent common bile duct (CBD) stones. Laparoscopic cholecystectomy (LC) after removal of CBD stones using endoscopic retrograde cholangiopancreatography (ERCP) is the most widely used method for treating coexisting gallbladder and common bile duct stones. We evaluated the optimal timing of LC after ERCP according to clinical factors, focusing on preoperative relief of jaundice. Methods: A total of 281 patients who underwent elective LC after ERCP because of choledocholithiasis and cholecystolithiasis from January 2010 to April 2018 were retrospectively reviewed. We compared the hospital stay, perioperative morbidity, and rate of surgical conversion to open cholecystectomy according to the relief of jaundice before surgery. These enrolled patients were divided into two groups: relief of jaundice before surgery (group 1, n = 125) or not (group 2, n = 156). Results: The initial total bilirubin level was higher in group 1; however, there were no significant differences in the other baseline characteristics including age, sex, American Society of Anesthesiologists score, previous surgical history, white blood cell count, C-reactive protein, and operative time between the two groups. There was also no significant difference in postoperative hospital stay between the two groups (4.5 ± 3.3 vs. 5.5 ± 5.6 days, p = 0.087). However, after ERCP, the waiting time until LC was significantly longer in group 1 (5.0 ± 4.9 vs. 3.5 ± 2.4 days, p < 0.001). There were no statistical differences in the conversion rate (3.2% vs. 3.8%, p = 0.518) or perioperative morbidity (4.0% vs. 5.8%, p = 0.348), either. Conclusions: LC would not be delayed until the relief of jaundice after ERCP since there were no significant differences in perioperative morbidity or surgical conversion rate to open cholecystectomy. Early LC after ERCP may be feasible and safe in patients with cholangitis and cholecystolithiasis.

Safety, quality and efficiency of intra-operative imaging for treatment decisions in patients with suspected choledocholithiasis without pre-operative magnetic resonance cholangiopancreatography

INTRODUCTION

Cholecystectomy is the accepted treatment for patients with symptomatic gallstones. In this study, we evaluate a simplified strategy for managing suspected synchronous choledocholithiasis by focussing on intra-operative imaging as the primary decision-making tool to target common bile duct (CBD) stone treatment.

METHODS

All elective and emergency patients undergoing laparoscopic cholecystectomy (LC) for gallstones with any markers of synchronous choledocholithiasis were included. Patients unfit for surgery or who had pre-operative proof of choledocholithiasis were excluded. Intra-operative imaging was used for evaluation of the CBD. CBD stone treatment was with bile duct exploration (LCBDE) or endoscopic retrograde cholangiopancreatography (LC + ERCP). Outcomes were safety, effectiveness and efficiency.

RESULTS

506 patients were included. 371 (73%) had laparoscopic ultrasound (LUS), 80 (16%) had on-table cholangiography (OTC) and 55 (11%) had both. 164 (32.4%) were found to have CBD stones. There was no increase in length of surgery for LC + LUS compared with average time for LC only in our unit (p = 0.17). 332 patients (65.6%) had clear ducts. Imaging was indeterminate in 10 (2%) patients. Overall morbidity was 10.5%. There was no mortality. 142 (86.6%) patients with stones on intra-operative imaging proceeded to LCBDE. 22 (13.4%) patients had ERCP. Sensitivity and specificity of intra-operative imaging were 93.3 and 99.1%, respectively. Success rate of LCBDE was 95.8%. Effectiveness was 97.8%.

CONCLUSIONS

Eliminating pre-operative bile duct imaging in favour of intra-operative imaging is safe and effective. When combined with intra-operative stone treatment, this method becomes a true 'single-stage' approach to managing suspected choledocholithiasis.

Lessons learnt from the first 200 unselected consecutive cases of laparoscopic exploration of common bile duct stones at a district general hospital

BACKGROUND

The management of choledocholithiasis evolves with diagnostic imaging and therapeutic technology, facilitating a laparoscopic approach. We review our first 200 cases of laparoscopic exploration of the common bile duct, highlighting challenges and lessons learnt.

METHODS

We retrospectively studied the first 200 cases of laparoscopic cholecystectomy with common bile duct exploration between 2006 and 2019. The database contains demographics, clinicopathological characteristics, diagnostic modalities, operative techniques, duration and outcomes.

RESULTS

We compared two approaches: transcystic vs. transcholedochal in our 200 cases. Choledocholithiasis was suspected preoperatively in 163 patients. 21 cases found no stones. Of the remainder, 111/179 cases were completed via the transcystic route and the remaining were completed transcholedochally (68/179); 25% of the transcholedochal cases were converted from a transcystic approach. CBD diameter for transcystic route was 8.2 vs. 11.0 mm for transcholedochal. Total clearance rate was 84%. Retained or recurrent stones were noted in 7 patients. Length of stay was 5.8 days, 3.5 days in the transcystic route vs. 9.4 days after transcholedochal clearance. Eight patients required re-operation for bleeding or bile leak. No mortalities were recorded in this cohort, but 2 cases (1%) developed a subsequent CBD stricture.

CONCLUSION

Concomitant laparoscopic common bile duct clearance with cholecystectomy is feasible, safe and effective in a district general hospital, despite constraints of time and resources. The transcystic route has a lower complication rate and shorter hospital stay, and hence our preference of this route for all cases. Advancements in stone management technology will allow wider adoption of this technique, benefitting more patients.

Retrospective comparative analysis of choledochoscopic bile duct exploration versus ERCP for bile duct stones

Debate still exists for the management of choledocholithiasis. The purpose of this study is to quantify the rate of recurrent choledocholithiasis post choledochoscopic bile duct exploration (CBDE) in comparison to ERCP and sphincterotomy, and to demonstrate the feasibility of this approach in a busy metropolitan hospital. Data of patients undergoing CBDE from 2009–2014 at the Northern Hospital, Victoria, Australia, was collected retrospectively. Primary outcomes were bile duct clearance rate and rate of recurrent stones post-clearance. Secondary outcomes measured were post-operative complications, laparoscopic to open conversion rate and operative time. Data of patients undergoing ERCP at the same institution was collected and compared. In total, there were 4,091 cholecystectomy cases performed from 2009–2014, of which 260 (6.3%) of patients had an intraoperative cholangiography (IOC) indicating a common bile duct (CBD) stone. Two hundred and forty-eight patients (95.3%) had a CBDE. The remaining 12 patients (4.6%) had radiological clearance, which were excluded from the study. The overall clearance rate for patients undergoing CBDE was 84% (209/248). The risk of recurrent stones up to 8 years post clearance was 2% (4/209). In the same institution, and between 1998–2012, a total of 1,148 patients underwent ERCP, of which 571 had endoscopic sphincterotomy (ES). Forty-three patients required a repeat ERCP for recurrent CBD stones with a complication rate of 7.5%. Time to recurrence ranged from 6 months to 10 years with a mean of 4.5 years. The rate of recurrence was lower in the CBDE group compared to the patients who had an ERCP (8.9% vs. 2%). CBDE is a feasible and effective method for clearance of CBD stones at the time of laparoscopic cholecystectomy. This approach, although not widely used, reduces the need for ERCP, which has inherent complications. In the longer term, this series showed a significant reduction in the rate of CBD stone recurrence.

The Treatment of Gallstone Disease

BACKGROUND

Gallstone disease affects up to 20% of the European population, and cholelithiasis is the most common reason for hospitalization in gastroenterology.

METHODS

This review is based on pertinent publications retrieved by a selective search of the literature, including the German clinical practice guidelines on the diagnosis and treatment of gallstones and corresponding guidelines from abroad.

RESULTS

Regular physical activity and an appropriate diet are the most important measures for the prevention of gallstone disease. Transcutaneous ultrasonography is the paramount method of diagnosing gallstones. Endoscopic retrograde cholangiography should only be carried out as part of a planned therapeutic intervention; endosonography beforehand lessens the number of endoscopic retrograde cholangiographies that need to be performed. Cholecystectomy is indicated for patients with symptomatic gallstones or sludge. This should be performed laparoscopically with a four-trocar technique, if possible. Routine perioperative antibiotic prophylaxis is not necessary. Cholecystectomy can be performed in any trimester of pregnancy, if urgently indicated. Acute cholecystitis is an indication for early laparoscopic cholecystectomy within 24 hours of admission to hospital. After successful endoscopic clearance of the biliary pathway, patients who also have cholelithiasis should undergo laparoscopic cholecystectomy within 72 hours.

CONCLUSION

The timing of treatment for gallstone disease is an essential determinant of therapeutic success.

[Russian consensus on current issues in the diagnosis and treatment of obstructive jaundice syndrome]

The Russian consensus document on topical issues of the diagnosis and treatment of obstructive jaundice syndrome was prepared by a group of experts in various fields of surgery, endoscopy, interventional radiology, radiological diagnosis and intensive care. The goal of this document is to clarify and consolidate the opinions of national experts on the following issues: timing of diagnosis of obstructive jaundice, features of diagnostic measures, the need and possibility of conservative measures for obstructive jaundice, and strategy of biliary decompression depending on the cause and level of biliary block.

Guillain-Barré syndrome complicated by takotsubo cardiomyopathy: an under-recognised association

A 41-year-old woman was admitted with progressive paraesthesia and weakness and was diagnosed with Guillain-Barré syndrome. Following an initial period of recovery with intravenous immunoglobulin treatment, she developed acute chest pain associated with electrocardiographic changes. Investigations excluded acute coronary syndrome and instead confirmed a diagnosis of takotsubo cardiomyopathy, which was treated medically. The patient made an excellent neurological and cardiac recovery. Here we discuss the rarely described association between these two conditions and suggest that patients admitted with Guillain-Barré syndrome may benefit from routine screening with echocardiography.

Clinical Efficacy Analysis of the Combination of the Laparoscope and Preoperative or Intraoperative Duodenoscope in the Treatment of Cholecystolithiasis with Choledocholithiasis: A Retrospective Study

Aim: This study aims to analyze the efficacy and safety of the combination of laparoscope and preoperative (PODL) or intraoperative (IODL) duodenoscope in the treatment of cholecystolithiasis with choledocholithiasis.

Materials and Methods: From January 2015 to February 2017, 51 patients with cholecystolithiasis and choledocholithiasis, who were treated with the PODL (n = 29) or IODL (n = 22), were reviewed retrospectively. The efficacy and safety were evaluated and compared between these two groups.

Results: The success rates were 100% in IODL group and 96.6% in PODL group. There was no statistical significance in the difference of stone clearance rate and residual stone rate between two groups (P > .05). There were no significant differences in complications, like aspiration, gastrointestinal perforation, and acute cholangitis between two groups (P > .05). IODL significantly decreased numeric rating scale (NRS) scoring, reduced surgery cost and shortened hospitalization time compared to that of PODL group (P < .05). No cholangitis, reoccurrence of stones or biliary obstruction occurred in all 51 patients.

Conclusion: In this retrospective study, IODL was found superior to PODL. And the IODL can significantly decrease NRS scoring, reduce surgery cost and shorten hospitalization time.

Primary closure with knotless barbed suture versus traditional T-tube drainage after laparoscopic common bile duct exploration: a single-center medium-term experience

Objective

Primary closure of the common bile duct (CBD) after laparoscopic CBD exploration (LCBDE) is a technical challenge. The present study was performed to evaluate the safety and effectiveness of this surgical method.

Methods

This retrospective study of surgical efficacy and safety involved 79 patients who underwent primary CBD closure with a knotless unidirectional barbed suture or traditional T-tube drainage after LCBDE for CBD stones.

Results

The average suturing time, operation time, and postoperative hospital stay were significantly shorter in the primary closure group than T-tube group. There were no significant differences in the mean diameter of the CBD, number of stones, or incidence of postoperative complications between the two groups. No patients developed recurrence of CBD stones during the median follow-up of 21.5 months.

Conclusions

After LCBDE and intraoperative choledochoscopy, primary closure with knotless unidirectional barbed sutures is a safe and effective therapeutic option for patients with cholelithiasis and concurrent CBD stones. This is especially true when the CBD is dilated more than 8 mm.

Laparoscopic Transcystic Common Bile Duct Exploration in the Emergency Is as Effective and Safe as in Elective Setting

BACKGROUND

Emergent laparoscopic transcystic common bile duct exploration (LTCBDE) has been reported to be on the increase in some institutions, reflecting the growing confidence with the technique. However, no study has focused on the outcomes of LTCBDE in the non-elective setting. The aim of this study is to investigate whether LTCBDE can be performed effectively and safely in the emergency.

METHODS

This is a retrospective study of 500 consecutive patients with choledocholithiasis subjected for LTCBDE at the Hospital Italiano de Buenos Aires from January 2009 to January 2018. Procedures were classified according to the setting as emergent or elective. Demographic data and perioperative parameters were compared between groups.

RESULTS

Throughout the period comprised, 500 patients were admitted for choledocholithiasis and gallstones. A single-step treatment combining LTCBDE and laparoscopic cholecystectomy was attempted: 211 (42.2%) were performed electively and the 289 (57.8%) as an emergency. There was no significant difference in the success rate of LTCBDE (93.9% versus 93.8%, p = 0.975) for the two groups. The operative time was slightly longer in the emergency group (122 ± 63 versus 106 ± 53 min, p = 0.002). Postoperative recovery was slower in the emergency group, as reflected by a higher rate of prolonged postoperative stay (21.1% vs 5.7%, p < .001). The rates of postoperative complications were similar between groups (2.8% vs 5.9%, p = 0.109).

CONCLUSION

Emergent LTCBDE can be performed with equivalent efficacy and morbidity when compared to an elective procedure. Patients undergoing emergent procedures have longer procedures and hospital stays.

Choledocholithiasis recurrence following laparoscopic common bile duct exploration

INTRODUCTION

Choledocholithiasis may be treated following an endoscopic approach or by laparoscopic common bile duct exploration (LCBDE). Stone recurrence following endoscopic management has been extensively investigated. We analyze the risk factors associated with stone recurrence following LCBDE.

METHODS

Patients who underwent LCBDE from February 2004 to July 2016 were examined in an univariate and multivariate analysis to assess the association of stone recurrence with the following variables: gender; age; hepatopathy; dyslipidemia, obesity or diabetes mellitus; previous abdominal surgery; presence of cholecystitis, cholangitis or pancreatitis; preoperative liver function tests, number of retrieved stones; method of common bile duct clearance and closure; presence of impacted or intrahepatic stones; conversion to open surgery and postoperative morbidity.

RESULTS

A total of 156 patients were included. Recurrence rate for choledocholithiasis was 14.1% with a mean time to recurrence of 38.18 month. Age was the only independent risk factor for stone recurrence at univariate and multivariate analysis. No patient aged under 55 years developed new common bile duct stones, and 86.4% of the recurrences occurred in patients aged above 65.

CONCLUSIONS

Age is the only independent risk factor associated to choledocholithiasis recurrence following LCBDE. Different mechanism in common bile duct stone development may be present for younger and older patients.

Management of Pediatric Patients Presenting with Acute Abdomen Accompanying Dilatation of the Common Bile Duct

PURPOSE

The aim of this study was to describe our treatment experiences with patients who had acute abdomen (AA) with common bile duct (CBD) dilatation.

METHODS

The treatment outcomes in children with AA and CBD dilatation were retrospectively reviewed. According to the shape of the intrahepatic bile ducts on ultrasonography (US), the origin of the pain was estimated as choledochal cyst (CC) complication or choledocholithiasis in normal CBD. Patients with complicated CC underwent surgery, and patients with choledocholithiasis in a normal appearing CBD underwent symptomatic treatment initially.

RESULTS

Of the 34 patients, 30 (88.2%) were female. The mean age of the patients was 6.4±4.9 (range, 0.8-17) years. Seventeen (50.0%) patients had CBD stones and 17 (50.0%) did not. Surgical treatment was performed in 20 (58.8%) patients, 2 of whom underwent preoperative stone removal with endoscopic retrograde cholangiopancreatography and an operation. Conservative treatment was applied in 12 (35.3%) patients (8 with and 4 without stones), 1 of whom developed symptom relapse and underwent an operation. Among the 8 patients with CBD stones, 4 (4/17, 23.5%) had complete resolution of the stones and recovery of the CBD diameter after conservative treatment. US findings of patients with stone showed a fusiform or cylindrical shape of the CBD in 14 (82.4%) patients.

CONCLUSION

The presence of stones in the distal CBD and the US features of CBD dilatation may be helpful to diagnose and treat the causes of biliary dilatation. Conservative treatment can be considered as initial therapy in patients with uncomplicated CBD dilatation with stone.

Efficacy of fibrin-sealants in reducing biliary leakage following laparoscopic common bile duct exploration

INTRODUCTION

In spite of the acquired experience with laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis management, there is still a risk of biliary leakage of 5% to 15% following choledochotomy closure. We evaluate the usefulness of fibrin-collagen sealants to reduce the incidence of biliary fistula after laparoscopic choledochorrhaphy.

METHODS

We report a retrospective analysis of 96 patients undergoing LCBDE from March 2009 to March 2017, whose closure of the bile duct was completed by antegrade stenting and choledochorraphy or by performing a primary suture. The study population was divided into two groups according to whether they received a collagen-fibrin sealant covering the choledochorrhaphy or not, analyzing the incidence of postoperative biliary fistula in each group.

RESULTS

Thirty-nine patients (41%) received a fibrin-collagen sponge while the bile duct closure was not covered in the remaining 57 patients (59%). The incidence of biliary fistula was 7.7% (3 patients) in the first group and 14% (8 patients) in the second group (P=.338). In patients who underwent primary choledochorraphy, the fibrin-collagen sealant reduced the incidence of biliary leakage significantly (4.5% vs. 33%, P=.020), which was a protective factor with an odds ratio of 10.5.

CONCLUSION

Fibrin-collagen sealants may decrease the incidence of biliary fistula in patients who have undergone primary bile duct closure following LCBDE.

Laparoscopic-endoscopic rendezvous versus preoperative endoscopic sphincterotomy in people undergoing laparoscopic cholecystectomy for stones in the gallbladder and bile duct

BACKGROUND

The management of gallbladder stones (lithiasis) concomitant with bile duct stones is controversial. The more frequent approach is a two-stage procedure, with endoscopic sphincterotomy and stone removal from the bile duct followed by laparoscopic cholecystectomy. The laparoscopic-endoscopic rendezvous combines the two techniques in a single-stage operation.

OBJECTIVES

To compare the benefits and harms of endoscopic sphincterotomy and stone removal followed by laparoscopic cholecystectomy (the single-stage rendezvous technique) versus preoperative endoscopic sphincterotomy followed by laparoscopic cholecystectomy (two stages) in people with gallbladder and common bile duct stones.

SEARCH METHODS

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, Science Citation Index Expanded Web of Science, and two trials registers (February 2017).

SELECTION CRITERIA

We included randomised clinical trials that enrolled people with concomitant gallbladder and common bile duct stones, regardless of clinical status or diagnostic work-up, and compared laparoscopic-endoscopic rendezvous versus preoperative endoscopic sphincterotomy procedures in people undergoing laparoscopic cholecystectomy. We excluded other endoscopic or surgical methods of intraoperative clearance of the bile duct, e.g. non-aided intraoperative endoscopic retrograde cholangiopancreatography or laparoscopic choledocholithotomy (surgical incision of the common bile duct for removal of bile duct stones).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane.

MAIN RESULTS

We included five randomised clinical trials with 517 participants (257 underwent a laparoscopic-endoscopic rendezvous technique versus 260 underwent a sequential approach), which fulfilled our inclusion criteria and provided data for analysis. Trial participants were scheduled for laparoscopic cholecystectomy because of suspected cholecysto-choledocholithiasis. Male/female ratio was 0.7; age of men and women ranged from 21 years to 87 years. The run-in and follow-up periods of the trials ranged from 32 months to 84 months. Overall, the five trials were judged at high risk of bias. Athough all trials measured mortality, there was just one death reported in one trial, in the laparoscopic-endoscopic rendezvous group (low-quality evidence). The overall morbidity (surgical morbidity plus general morbidity) may be lower with laparoscopic rendezvous (RR 0.59, 95% CI 0.29 to 1.20; participants = 434, trials = 4; I² = 28%; low-quality evidence); the effect was a little more certain when a fixed-effect model was used (RR 0.56, 95% CI 0.32 to 0.99). There was insufficient evidence to determine the effects of the two approaches on the failure of primary clearance of the bile duct (RR 0.55, 95% CI 0.22 to 1.38; participants = 517; trials = 5; I² = 58%; very low-quality evidence). The effects of either approach on clinical post-operative pancreatitis were unclear (RR 0.29, 95% CI 0.07 to 1.12; participants = 517, trials = 5; I² = 24%; low-quality evidence). Hospital stay appeared to be lower in the laparoscopic-endoscopic rendezvous group by about three days (95% CI 3.51 to 2.50 days shorter; 515 participants in five trials; low-quality evidence). There was very low-quality evidence that suggested longer operative time with laparoscopic-endoscopic rendezvous (MD 34.07 minutes, 95% CI 11.41 to 56.74; participants = 313; trials = 3; I² = 93%). The Trial Sequential Analyses of operating time and the length of hospital stay indicated that all the trials crossed the conventional boundaries, suggesting that the sample sizes were adequate, with a low risk of random error.

AUTHORS' CONCLUSIONS

There was insufficient evidence to determine the effects of the laparoscopic-endoscopic rendezvous versus preoperative endoscopic sphincterotomy techniques in people undergoing laparoscopic cholecystectomy on mortality and morbidity. The laparoscopic-endoscopic rendezvous procedure may lead to longer operating times, but it may reduce the length of the hospital stay when compared with preoperative endoscopic sphincterotomy followed by laparoscopic cholecystectomy. However, no firm conclusions could be drawn because the quality of evidence was low or very low. If confirmed by future trials, these data might re-design the scenario of treatment of this condition, albeit requiring greater organisational effort. Future trials should also address issues such as quality of life and cost analysis.

Single-stage procedure for the treatment of cholecysto-choledocolithiasis: a surgical procedures review

While laparoscopic cholecystectomy is generally accepted as the treatment of choice for simple gallbladder stones, in cases in which common bile duct stones are also present, clinical and diagnostic elements, along with intraoperative findings, define the optimal means of treatment. All available options must be accessible to the surgical team which must necessarily be multidisciplinary and include a surgeon, an endoscopist, and a radiologist in order to identify the best option for a truly personalized surgery. This review describes the different techniques and approaches used based on distinctive recommendations and factors, according to the specific cases treated and the results achieved.

Inpatient Choledocholithiasis Requiring ERCP and Cholecystectomy: Outcomes of a Combined Single Inpatient Procedure Versus Separate-Session Procedures

OBJECTIVES

Separate-session endoscopic retrograde cholangiography (ERCP) and laparoscopic cholecystectomy (LC) is the usual method for management of inpatient choledocholithiasis. Our goal was to compare single operative-session LC and ERCP to a multi-session approach for both the same hospitalization and within 30 days after; there is limited data comparing the three groups.

METHODS

A retrospective review on inpatients with choledocholithiasis that underwent ERCP and LC was performed. Single operative-session ERCP + LC (SOS group) and separate hospitalization ERCP + LC (DH group) were compared against the control cohort: separate-session ERCP + LC performed during the same hospitalization (SH group).

RESULTS

Among the 214 cases, 37 (17%) had LC + ERCP performed under a single operative session (SOS), 130 (60.7%) cases had LC + ERCP performed in separate operative sessions during the same hospitalization (SH), and 47 (22%) cases had LC + ERCP performed in different hospitalizations, within 30 days (DH). There was no statistically significant difference in efficacy or adverse events. The SOS group had a statistically significant mean shorter length of hospital stay as compared to the SH and DH groups (5.46 vs 7.15 vs 9.38; p = 0.05 and 0.02). There was a statistically significant reduction in the total cost of care in the SOS group versus the SH group ($59,221 vs $75, 808; p = 0.007).

CONCLUSION

The SOS approach is safe, efficacious, and cost-efficient when compared to separate operative sessions. This approach can be considered in situations where it is preferable for the patient to undergo a single session of anesthesia, without compromising technical success and safety.

Simultaneous common bile duct clearance and laparoscopic cholecystectomy: experience of a one-stage approach

Introduction

The timing and optimal method for common bile duct (CBD) clearance and laparoscopic cholecystectomy remains controversial. Several different approaches are available in clinical practice. The current study presents the experience of two European hospitals of simultaneous laparoscopic cholecystectomy (LC) and intra-operative endoscopic retrograde cholangiopacreatography (IO-ERCP) done by surgeons.

Methods

Retrospective analysis of all consecutive patients subjected to LC + IO-ERCP during their index admission between 4/2014 and 9/2016. Data accrued included patient demographics, laboratory markers, operation time (min) reported as mean (± SD) and hospital length of stay (LOS) reported as median (lower quartile, upper quartile).

Results

During the 29-month study, a total of 201 consecutive LC + IO-ERCPs were performed. The mean age of patients was 55 ± 19 years and 67% were female. The mean intervention time was 105 ± 44 min. The total LOS was 4 (3,  7) days and the post-operative LOS was 2 (1,  3) days. A total of 6 (3%) patients experienced post-interventional pancreatitis and two (1%) patients suffered a Strasberg type A bile leak. All patients were successfully discharged.

Conclusion

Simultaneous LC + IO-ERCP is associated with few complications. Further studies investigating cost-benefit and patient satisfaction are warranted.

Efficacy and safety of laparoscopic bile duct exploration versus endoscopic sphincterotomy for concomitant gallstones and common bile duct stones: A meta-analysis of randomized controlled trials

BACKGROUND

The purpose of this study was to compare the efficacy and safety of laparoscopic cholecystectomy (LC) plus laparoscopic common bile duct (CBD) stones exploration (LCBDE) with LC plus endoscopic sphincterotomy (EST) in the treatment of patients with gallstones and CBD stones.

METHODS

The authors searched PubMed, Web of Science, and Embase to identify relevant studies. Risk ratios (RRs) were pooled to compare stone clear, retained stone, conversion to other procedures, and complications. Weighted mean differences (WMDs) were pooled to compare operative time, and length of hospital stay. A fixed-effects model or random-effects model was used to pool the estimates, according to the heterogeneity among the included studies.

RESULTS

A total of 11 randomized controlled trials (RCTs) involving 1663 patients were included in this meta-analysis. The pooled estimate suggested that LC-LCBDE had comparable effects with LC-EST in terms of CBD stone clear rate (RR = 1.02, 95% CI: 0.95, 1.09; P = .583), retained stones rate (RR = 1.27, 95% CI: 0.51, 3.19; P = .607), and length of hospital stay (WMD = -0.96 days, 95% CI: -2.20, 0.28). In addition, LC-LCBDE was associated with significantly higher conversion rate (RR = 1.59, 95% CI: 1.08, 2.35; P = .019) and less operative time (WMD = -11.55 minutes, 95% CI: -16.68, -6.42; P < .001) than LC-EST. The incidence of complications was not significant difference between the 2 surgical approaches (RR = 1.07, 95% CI: 0.86, 1.34; P = .550).

CONCLUSION

Based on the current evidence, both LC-LCBDE and LC-EST were highly effective in detecting and removing CBD stones and were equivalent in complications. However, our results might be biased by the limitations. Large-scale well-designed RCTs are needed to confirm our findings.

Antegrade jejunogastric intussusception and common bile duct stones at 14 months after gastrectomy and cholecystectomy: A case report

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Jejunogastric intussusception occurred after distal gastrectomy followed by Roux-en Y reconstruction.

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Common bile duct stone occurred after prophylactic cholecystectomy and distal gastrectomy.

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Intussusception and common bile duct stone both could occur simultaneously after gastrectomy.

Introduction

Intussusception after gastrectomy is a minor complication after gastrectomy, while common bile duct stone (CBD) is also a rare complication post cholecystectomy. We report a case that simultaneously caused both intussusception and CBD stone following gastrectomy with prophylactic cholecystectomy.

Case presentation

A 74-year-old woman underwent distal gastrectomy with Roux-en-Y reconstruction and prophylactic cholecystectomy for gastric cancer. After 14 months, the patient reported nausea and vomiting. Abdominal computed tomography scanning showed antegrade intussusception of the Roux limb of the gastrojejunostomy and calculi in the common bile duct, with a diagnosis of jejunogastric intussusception and common bile duct stones. The patient was hospitalized and endoscopic examination was performed on day 3. Endoscopic treatment did not resolve the intussusception, which also obstructed the bile duct stones. Elective surgery was performed on day 10, in which the invaginated Roux limb of the gastrojejunostomy was resected after manual reinstatement to its original position. This was followed by open exploration of the common bile duct and T-tube drainage. The patient was discharged 25 days post- surgery.

Discussion

Jejunogastric intussusception and CBD stone may require operative management, although the operation could be elective after sufficient examination and preparation.

Conclusion

Jejunogastric intussusception and bile duct stones are rare after distal gastrectomy, physicians should be alerted to the possibility of these complications.

Comparison of one stage laparoscopic cholecystectomy combined with intra-operative endoscopic sphincterotomy versus two-stage pre-operative endoscopic sphincterotomy followed by laparoscopic cholecystectomy for the management of pre-operatively diagnosed patients with common bile duct stones: A meta-analysis. Surg Endosc. 2018;32:770-778. [PMID: 28733744 DOI: 10.1007/s00464-017-5739-y]

BACKGROUND

Laparoscopic cholecystectomy (LC) for symptomatic gallstone disease is one of the most common surgical procedures. Concomitant common bile duct (CBD) stones are detected with an incidence of 4-20% and the ideal management is still controversial. The frequent practice is to perform endoscopic sphincterotomy pre-operatively (POES) followed by LC, to allow subsequent laparoscopic or open exploration if POES fails. However, POES has shown different drawbacks such as need for two hospital admissions, need of two anesthesia inductions, higher rate of pancreatitis, and longer hospital stay. Hence, an intra-operative endoscopic sphincerotomy (IOES) has been proposed.

OBJECTIVE

To compare the 1 stage laparoscopic cholecystectomy (LC) combined with IOES versus 2-stage POES followed by LC for the management of pre-operatively known cholecystocholedocholithiasis.

SEARCH STRATEGY

The search terms bile duct stones/calculi, ERCP, endoscopic sphincterotomy, laparoendoscopic rendezvous (LERV), and laparoscopic ductal clearance/choledochotomy/exploration were used. A comprehensive hand-based search of reference lists of published articles and review articles was performed to ensure inclusion of all possible studies and exclude duplicates.

SELECTION CRITERIA

RCTs comparing 1 stage LC combined with IOES versus 2-stage POES followed by LC for the management of pre-operatively known cholecystocholedocholithiasis in adults.

DATA COLLECTION & ANALYSIS

Three reviewers assessed trial quality and extracted the data. Data were entered in revman version 5.3. The trials were grouped according to the outcome measure assessed such as success rate of CBD stone clearance, incidence of pancreatitis, overall morbidity, and length of hospital stay.

MAIN RESULTS

A total of 629 patients in 5 RCTs met the inclusion criteria. The success rate of CBD clearance (IOES = 93%, POES = 92%) was the same in both groups (OR 1.34; 95% CI 0.45-0.97; p = 0.60). Findings showed that IOES was associated with less pancreatitis (0.6%) than POES (4.4%) (OR 0.19; 95% CI 0.06-0.67; p = 0.01; I ² = 43%). The incidence of overall morbidity was lower in the IOES group (6%) than the POES group (11%) (OR 0.54; 95% CI 0.31-0.96; p = 0.03; I ² = 20%). The mean days of hospital stay for IOES group (M = 3.52, SD = 1.434, N = 5) was significantly less than the POES group (M = 6.10, SD = 2.074, N = 5), t(8) = 2.29, p <= 0.051.

CONCLUSION

IOES is at par with two-stage POES in terms of CBD clearance, with less incidence of post-operative pancreatitis, overall morbidity, and less hospital stay.

Endoscopic versus laparoscopic treatment for choledocholithiasis: a prospective randomized controlled trial

Background and study aims: Overall, 5 % to 15 % of patients undergoing cholecystectomy for cholelithiasis have concomitant bile duct stones, and the incidence of choledocholithiasis increases with age. There is no clear consensus on the best therapeutic approach (endoscopic versus surgical). Patients and methods: A prospective randomized controlled clinical trial was performed to compare three treatment options for patients with choledocholithiasis at the National Center for Minimally Invasive Surgery in Havana, Cuba from November 2007 to November 2011. The patients were randomized in three groups. Group I: patients who underwent intraoperative cholangiography (IOC) to confirm the choledocholithiasis followed by laparoscopic cholecystectomy (LC) associated with intraoperative endoscopic retrograde cholangiopancreatography (ERCP), group II: patients who underwent preoperative ERCP followed by LC during the same hospital admission and group III: patients who underwent IOC to confirm the choledocholithiasis followed by LC associated with laparoscopic common bile duct exploration (LCBDE). Results: A total of 300 patients with suspected choledocholithiasis were included in the trial and were randomized. As a result, a total of 134 patients were diagnosed with the presence of choledocholithiasis and treated during the study period. There were no significant differences in success rates of ductal stone clearance, but retained stone, postoperative complications and length of hospital stay were better in group I. Conclusions: Intraoperative ERCP/ES shows a higher rate of common bile duct stones clearance, a shorter hospital stay, and lower morbidity, but further research with a larger study population is necessary to determine the additional benefits of this procedure. The results to date suggests that in appropriate patients, single-stage treatments are the best options.

Choledocholithiasis: Evaluation, Treatment, and Outcomes

Choledocholithiasis occurs in up to approximately 20% of patients with cholelithiasis. A majority of stones form in the gallbladder and then pass into the common bile duct, where they generate symptoms, due to biliary obstruction. Confirmatory diagnosis of choledocholithiasis is made with advanced imaging, including magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP). Treatment varies locally; however, ERCP with sphincterotomy is most commonly employed with a high degree of success. Difficult anatomy and difficult stone burden require advanced surgical, endoscopic, and percutaneous techniques to extract or expel biliary stones. Knowledge of these treatment strategies will optimize outcomes.

LABEL procedure: Laser-Assisted Bile duct Exploration by Laparoendoscopy for choledocholithiasis: improving surgical outcomes and reducing technical failure

BACKGROUND

Laparoscopic bile duct exploration (LBDE) is recommended in current treatment guidelines for the management of choledocholithiasis with gallbladder in situ. Failure of this technique is common as a consequence of large or impacted common bile duct (CBD) stones. In this series, we present our experience in using holmium laser lithotripsy as an adjunct to LBDE for the treatment of choledocholithiasis.

METHODS

Between 2014 and 2016, eighteen laparoscopic bile duct explorations utilising holmium laser lithotripsy were performed after failure of standard retrieval techniques.

RESULTS

Choledocholithiasis was successfully treated in 18 patients using laparoscopic holmium laser lithotripsy (transcystically in 14 patients). There was one failure where a CBD stricture prevented the scope reaching the stone. Two medical complications were recorded (Clavien-Dindo I and II). There were no mortalities or re-interventions.

CONCLUSIONS

LABEL technique is a successful and safe method to enhance LBDE in cases of impacted or large stones. In our experience, this approach increases the feasibility of the transcystic stone retrieval and may reduce overall operative time.

Spontaneous Perforation of Common Bile Duct: A Rare Presentation of Gall Stones Disease

Background. Spontaneous perforation of the extrahepatic biliary system is a rare presentation of gall stones. Very few cases of bile duct perforation have been reported in adults. It is rarely suspected or correctly diagnosed preoperatively. Case Presentation. A 66-year-old female presented at the surgical emergency with 3 days' history of severe upper abdominal pain with distension and repeated episodes of vomiting, as she had evidence of generalized peritonitis and underwent an exploratory laparotomy. A single 0.5 cm × 0.5 cm free perforation was present on the anterolateral surface of the common bile duct at the junction of cystic duct. A cholecystectomy and the CBD exploration were performed. Conclusion. Spontaneous perforation of the extrahepatic bile duct is a rare but important presentation of gall stones in adults. Therefore, awareness of the clinical presentation, expert ultrasound examination, and surgery are important aspects in the management.

Intraoperative ERCP for management of cholecystocholedocholithiasis

BACKGROUND

The introduction of minimally invasive techniques in management of biliary problems added new procedures for treating patients with cholecystocholedocholithiasis (CCL). This study presents the results of intraoperative ERCP (IOERCP) during LC as a single-session minimally invasive procedure for management of patients who have preoperatively diagnosed CBD stones.

METHODS

The database of patients presented to our center by CCL between October 2007 and December 2015 who were treated by LC and IOERCP was collected and analyzed. CBD stones were diagnosed using clinical data, laboratory tests and abdominal sonogram. MRCP was requested for doubtful cases. In the first cases ERCP was done using rendezvous technique, but in late cases standard ERCP immediately after completion of LC under the same anesthesia was used. Preoperative, intraoperative and postoperative data were recorded, analyzed and reported. Data reported include success/failure rate, complications, conversion to open surgery, operative details and incidence of residual CBD stones.

RESULTS

The study was conducted on 346 patients who had CCL. The mean age was 34.7 years, and 298 of them were females. The most common presentation was abdominal pain (98.5 %) and jaundice (64.9 %). Fifteen patients were excluded, and IOERCP was not done due to negative IOC results in 10 patients and conversion to open surgery in 5 patients. IOERCP was tried in the remaining 331 patients. The mean operative time was 55 min, and the mean hospital stay was 2.4 days. Major complications had been reported in 13/323 patients (4.0 %). Failure of CBD clearance was reported in 8 patients (2.4 %) with a success rate of 97.6 %. Thirty-day follow-up was possible in 142 patients, and there was a residual CBD stone in one patient and wound infection in another one.

CONCLUSIONS

IOERCP during LC is a safe and effective option for management of CCL.

Laparoscopic common bile duct exploration versus ERCP/stenting and cholecystectomy: Is a single staged procedure better?

Aims: Choledocholithiasis is most common cause of obstructive jaundice. Laparoscopic choledocholithotomy has evolved as an alternative procedure to ERCP/ stenting in the management of choledocholithiasis. This study was aimed to compare the outcomes of laparoscopic CBD exploration with cholecystectomy (group 1) as compared to the conventional two staged procedure involving ERCP/ stenting (group 2). Methods: 60 patients admitted to our department (mean age = 45.52, SD = 17.71, 15 males, 45 females) for the management of choledocholithiasis from April 2014 to October 2015 were included in the study. We reviewed retrospectively the patients' data including age, sex, duration of the surgery, intra-operative and postoperative complications, duration of hospital stay, mortality and condition on follow-up. Results: Group 1 included 30 patients (mean age 50.76, 21 females, 9 males). The average operative time in this group was 110 minutes (96–145), stone clearance rate was 100%, and average hospital stay was 3.2 days (2–9). Group 2 also included 30 patients (mean age 44.36, 24 females, 6 males) with stone clearance rate of 70% (21 out of 30), average operative time 120.7 minutes (90–167), average hospital stay 9.1 (3–30) days and an average of 2.3 procedures per patient. Conclusion: In our study mean operative time, stone clearance rate, average hospital stay and average number of procedures per patient were found to be significantly lower in laparoscopic CBD exploration group. It can be concluded that laparoscopic CBD exploration with cholecystectomy is much safer and cost effective than the conventional two staged procedure involving ERCP/ stenting.

The Role of Choledochoscopy in Hepatopancreatobiliary Diseases

OBJECTIVE

Advances in choledochoscopy technology lead to an improvement in the diagnosis and treatment of hepatopancreatobiliary diseases. The aim of this study is to reveal the role of choledochoscopy in hepatopancreatobiliary pathologies.

MATERIALS AND METHODS

Choledochoscopy was used under general anesthesia in operation rooms. Flexible choledochoscope inserted via a vertical choledochotomy line, which was closed by primary closure, T-tube application, or choledochoduodenal anastomosis. Olympus CHF T 20 flexible choledochoscope and related endoscopic instruments were used for the procedures. The records were evaluated retrospectively.

RESULTS

This study presents the findings of 235 intraoperative choledochoscopy procedures. The most common indications were suspected common bile duct stone in 96 patients (40.9%), serum cholestatic enzyme increase without jaundice in 52 (22.1%), obstructive jaundice and/or serum bilirubin increase in 46 (19.6%), and presence of dilated choledoch in 42 (17.9%). Additional endoscopic diagnostic and/or therapeutic procedures were performed 156 times in 125 patients (53.2%), and endoscopic biliary stone removal was the most used procedure (87 patients, 37.0%). The mean choledochoscopy duration was 8.5 minutes (range: 5-25 minutes). Choledochoscopy confirmed preliminary diagnosis in 117 patients (49.8%), while different data were elicited in 68 (28.9%), and normal findings were found in 50 (21.3%). In this series, no choledochoscopy-related mortality was seen, and some complications occurred in 4 patients (1.7%).

CONCLUSION

Intraoperative flexible choledochoscopy is a proper technique in the diagnosis and treatment of hepatopancreatobiliary disorders.

'Single-Sitting' Laparoscopic Cholecystectomy and Endoscopic Removal of Common Bile Duct Stone for Cholelithiasis and Choledocholithiasis: a Feasibility Study

'Single-sitting' laparoscopic cholecystectomy followed by endoscopic common bile duct clearance is emerging as a viable option for management of cholelithiasis and concomitant choledocholithiasis. The only disadvantage of the procedure is logistical since it requires co-ordination between two teams-the surgeons and the endoscopists. This limitation can be overcome in centres where both the procedures are performed by one team. With a considerable experience in endoscopy, we conducted a prospective study in a select group of patients to assess the feasibility of this single-sitting approach. The study included 38 patients with a radiological diagnosis of choledocholithiasis or jaundice at presentation. After laparoscopic cholecystectomy, the patients were turned prone and subjected to endoscopic retrograde cholangiogram, sphincterotomy and extraction of the common bile duct stone. The procedure was successful in 33 (87 %) of patients. The mean procedure time and hospital stay were 2 h, 20 min and 2 days, respectively. None of the patients had any major complications. We conclude that in a select group of patients, single-sitting laparoscopic cholecystectomy followed by endoscopic clearance of the common bile duct stone is safe and effective.

Transcystic or transductal stone extraction during single-stage treatment of choledochocystolithiasis: a systematic review

BACKGROUND

Choledochocystolithiasis can be managed by endoscopic retrograde cholangiopancreaticography (ERCP) or laparoscopically by transcystic (TC) or transductal (TD) stone extraction.

OBJECTIVE

The aim of this study was to systematically review safety and effectiveness of combined endoscopic/laparoscopic management versus total laparoscopic management for choledochocystolithiasis with specific emphasis on TC versus TD stone extraction.

METHODS

MEDLINE/PubMed, EMBASE, the Cochrane Library, and clinicaltrials.gov were searched systematically to identify trials on combined endoscopic/laparoscopic and total laparoscopic management for choledochocystolithiasis. Laparoscopic common bile duct (CBD) exploration was divided into TD and TC approach. Primary outcomes were successful stone clearance from CBD, postoperative/procedural morbidity, and mortality.

RESULTS

Eight randomized trials with 965 patients were included. Successful bile duct clearance varied between 52.6 and 97 % in the ERCP groups, 80.4 and 100 % in the TC groups, and 58.3 and 100 % in the TD groups. There were more bile leaks after TD stone extraction (11 %) than after ERCP (1 %) and TC stone extraction (1.7 %). Total morbidity varied between 9.1 and 38.3 % in the ERCP groups, 7 and 10.5 % in the TC groups, and 18.4 and 26.7 % in the TD groups. Methodological and statistical heterogeneity among the trials precluded a meaningful meta-analysis.

CONCLUSION

Stone clearance rates are comparable between the three modalities, but TD stone extraction is associated with a higher risk of bile leaks and should only be performed by highly experienced surgeons. TC stone extraction seems a more accessible technique with lower complication rates. If unsuccessful, per- or postoperative endoscopic stone extraction is a viable option.

Surgeons, ERCP, and laparoscopic common bile duct exploration: do we need a standard approach for common bile duct stones? Surg Endosc. 2016;30:414-423. [PMID: 26092008 DOI: 10.1007/s00464-015-4273-z]

BACKGROUND

Variation exists in the management of choledocholithiasis (CDL). This study evaluated associations between demographic and practice-related characteristics and CDL management.

METHODS

A 22-item, web-based survey was administered to US general surgeons. Respondents were classified into metropolitan or nonmetropolitan groups by zip code. Univariate tests and multivariable logistic regression were used to determine factors associated with CDL management preferences.

RESULTS

The survey was sent to 32,932 surgeons; 9902 performed laparoscopic cholecystectomy within the last year; 750 of 771 respondents had a valid US zip code and were included in the analysis. Mean practice time was 18 ± 10 years, 87% were male, and 83% practiced in a metropolitan area. For preoperatively known CDL, 86% chose preoperative endoscopic retrograde cholangiopancreatography (ERCP). Those in metropolitan areas were more likely to select preoperative ERCP than those in nonmetropolitan areas (88 vs. 79%, p < 0.001). For CDL discovered intraoperatively, 30% selected laparoscopic common bile duct exploration (LCBDE) as their preferred method of management with no difference between metropolitan and nonmetropolitan areas (30 vs. 26%, p = 0.335). The top reasons for not performing LCBDE were: having a reliable ERCP proceduralist available, lack of equipment, and lack of comfort performing LCBDE. Factors associated with preoperative ERCP were: metropolitan status, selective intraoperative cholangiography (IOC), and availability of a reliable ERCP proceduralist. Those who perform selective IOC were 70% less likely to prefer LCBDE (OR 0.32, 95% CI 0.18-0.57, p < 0.001). Those with a reliable ERCP proceduralist available were 90% less likely to prefer LCBDE (OR 0.10, 95% CI 0.04-0.26, p < 0.001).

CONCLUSIONS

The majority of respondents preferred ERCP for the management of CDL. Having a reliable ERCP proceduralist available, use of selective IOC, and metropolitan status were independently associated with preoperative ERCP. Postoperative ERCP was preferred for managing intraoperatively discovered CDL. Many surgeons are uncomfortable performing LCBDE, and increased training may be needed.

Common bile duct exploration in an elderly Asian population

Common bile duct exploration (CBDE) is an accepted treatment for choledocholithiasis. This procedure is not well studied in the elderly population. Here we evaluate the results of CBDE in elderly patients (>70 years) and compare the open (group A) with the laparoscopic group (group B). A retrospective review was performed of elderly patients with proven common bile duct (CBD) stones who underwent CBDE from January 2005 to December 2009. There were 55 patients in group A and 33 patients in group B. Mean age was 77.6 years (70-91 years). Both groups had similar demographics, liver function tests, and stone size-12 mm (range, 5-28 mm). Patients who had empyema (n = 9), acute cholecystitis (n = 15), and those who had had emergency surgery (n = 28) were more likely to be in group A (P < 0.05). The mean length of stay for group A was 11.7 ± 7.3 days; for group B, 5.2 ± 6.3 days; the complication rate was higher in group A (group A, 38.2%; group B, 8.5%; P = 0.072). The overall complication and mortality rate was 29.5% and 3.4%, respectively. CBDE can be performed safely in the elderly with accepted morbidity and mortality. The laparoscopic approach is feasible and safe in elective setting even in the elderly.

Percutaneous treatment of common bile duct stones: results and complications in 110 consecutive patients

BACKGROUND/AIMS

Choledocholithiasis is a common complication of cholecystolithiasis, occurring in 15-20% of patients who have gallbladder stones. Endoscopic retrograde cholangio-pancreatography is the standard treatment. When this is not possible or not feasible, percutaneous transhepatic stone removal is an alternative treatment. In this retrospective study, we analyze 110 patients who were treated with percutaneous transhepatic removal of Common Bile Duct (CBD) stones.

PATIENTS AND METHODS

Between March 1998 and September 2013 110 patients (61 men, 49 women; aged 14-96, mean age 69.7 years) with confirmed bile duct stones were included. PTC was done using ultrasound and fluoroscopy. Balloon dilatation of the papilla was done with 8-12 mm balloons. If stone size exceeded 10 mm, mechanical lithotripsy was performed. Stones were then removed by percutaneous extraction or evacuation into the duodenum.

RESULTS

In 104 patients (104/110; 94.5%) total stone clearance of the CBD was achieved. A total of 12 complications occurred (10.9%), graded with the Clavien-Dindo scale as IVa, IVb, and V, respectively; hypoxia requiring resuscitation, sepsis and death due to ongoing cholangiosepsis (n = 1, 4, 1). Minor complications I, II, and IIIa included: small liver abscess, pleural empyema, transient hemobilia and mild fever (n = 1, 1, 2, 2).

CONCLUSION

Percutaneous removal of CBD stones is an effective alternative treatment, when endoscopic treatment is contra-indicated, fails or is not feasible. It is effective, has a low complication rate and using deep sedation potentially requires only a very limited number of treatment sessions.

Imaging tests for accurate diagnosis of acute biliary pancreatitis

Gallstones represent the most frequent aetiology of acute pancreatitis in many statistics all over the world, estimated between 40%-60%. Accurate diagnosis of acute biliary pancreatitis (ABP) is of outmost importance because clearance of lithiasis [gallbladder and common bile duct (CBD)] rules out recurrences. Confirmation of biliary lithiasis is done by imaging. The sensitivity of the ultrasonography (US) in the detection of gallstones is over 95% in uncomplicated cases, but in ABP, sensitivity for gallstone detection is lower, being less than 80% due to the ileus and bowel distension. Sensitivity of transabdominal ultrasonography (TUS) for choledocolithiasis varies between 50%-80%, but the specificity is high, reaching 95%. Diameter of the bile duct may be orientative for diagnosis. Endoscopic ultrasonography (EUS) seems to be a more effective tool to diagnose ABP rather than endoscopic retrograde cholangiopancreatography (ERCP), which should be performed only for therapeutic purposes. As the sensitivity and specificity of computerized tomography are lower as compared to state-of-the-art magnetic resonance cholangiopancreatography (MRCP) or EUS, especially for small stones and small diameter of CBD, the later techniques are nowadays preferred for the evaluation of ABP patients. ERCP has the highest accuracy for the diagnosis of choledocholithiasis and is used as a reference standard in many studies, especially after sphincterotomy and balloon extraction of CBD stones. Laparoscopic ultrasonography is a useful tool for the intraoperative diagnosis of choledocholithiasis. Routine exploration of the CBD in cases of patients scheduled for cholecystectomy after an attack of ABP was not proven useful. A significant rate of the so-called idiopathic pancreatitis is actually caused by microlithiasis and/or biliary sludge. In conclusion, the general algorithm for CBD stone detection starts with anamnesis, serum biochemistry and then TUS, followed by EUS or MRCP. In the end, bile duct microscopic analysis may be performed by bile harvested during ERCP in case of recurrent attacks of ABP and these should be followed by laparoscopic cholecystectomy.

Factors significantly contributing to a failed conventional endoscopic stone clearance in patients with "difficult" choledecholithiasis: a single-center experience

The objective of this study is to retrospectively evaluate factors significantly contributing to a failed stone extraction (SE) in patients with difficult to extract bile duct stones (BDS). Patients and Methods. During a 10-year period 1390 patients with BDS underwent successfully endoscopic sphincterotomy. Endoscopic SE was graded as easy; relatively easy; difficult; and failed. Difficult SE was encountered in 221 patients while failed SE was encountered in 205. A retrospective analysis of the criteria governing the difficulty of endoscopic SE following the index endoscopic intervention was performed to evaluate their significance in determining failure of complete SE among patients with difficult to extract bile duct stones. Results. Age ≥ 85 years, periampullary diverticula, multiple CBD stones (>4), and diameter of CBD stones (≥15 mm) were all significant contributing factors to a failed SE in univariate statistical tests. In the definitive multivariate analysis age, multiple stones and diameter of stones were found to be the significant, independent contributors. Conclusion. Failed conventional endoscopic stone clearance in patients with difficult to extract BDS is more likely to occur in overage patients, in patients with multiple CBD stones >4, and in patients with CBD stone(s) diameter ≥15 mm.

Use of biliary stent in laparoscopic common bile duct exploration

INTRODUCTION

It is well supported in the literature that laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis has equal efficacy when compared to ERCP followed by laparoscopic cholecystectomy. Decompression after supra-duodenal choledochotomy is common practice as it reduced the risk of bile leaks. We conducted a prospective non-randomized study to compare outcomes and length of stay in patients undergoing biliary stent insertion versus T-tube drainage following LCBDE via choledochotomy.

METHODS AND PROCEDURES

The study involved 116 patients with choledocholithiasis who underwent LCBDE and decompression of the biliary system by either ante-grade biliary stent or T-tube insertion. A 7 French straight/duodenal curve biliary Diagmed™ stent (9-11 cm) was placed in 82 patients (Biliary Stent Group). T-tube insertion was used for 34 patients (T-tube group). The length of hospital stay and complications for the selected patients were recorded. All trans-cystic common bile duct explorations were excluded from the study.

RESULTS

The mean hospital stay for patients who underwent ante-grade biliary stent or T-tube insertion after LBCDE were 1 and 3.4 days, respectively. This is a statistically significant result with a p value of less than 0.001. Of the T-tube group, two patients required laparoscopic washout due to bile leaks, one had ongoing biliary stasis and one reported ongoing pain whilst the T-tube was in situ. A complication rate of 11.2%, this was a significant finding. There were no complications or concerns reported for the Biliary Stent Group.

CONCLUSION

Our results show that there is a significant reduction in length of hospital stay and morbidity for patients that have ante-grade biliary stent decompression of the CBD post laparoscopic choledochotomy when compared T-tube drainage. This implies that ante-grade biliary stent insertion is likely to reduce costs and increase overall patient satisfaction. We support the use of ante-grade biliary stent insertion during LCBDE when primary closure is not preferred.

Systematic review and meta-analysis of minimally invasive techniques for the management of cholecysto-choledocholithiasis

BACKGROUND

The optimal management of patients with symptomatic gallstones and possible or proven common bile duct (CBD) stones and gallstones is still evolving. Today a number of options exist: preoperative endoscopic retrograde cholangiopancreatography (pre-op ERCP), laparoscopic cholecystectomy (LC) combined with intraoperative endoscopic sphincterotomy (IOES), laparoscopic common bile duct exploration (LCBDE) and postoperative ERCP (post-op ERCP). This meta-analysis was done to compare these management options and determine if any single option was clearly superior.

METHODS

A systematic search was conducted using several electronic databases. The search revealed 15 randomized controlled trials (RCTs). Six comparing pre-op ERCP with LCBDE, five comparing pre-op ERCP with IOES, two comparing IOES with LCBDE and two comparing post-op ERCP with LCBDE, comprising a total of 1992 patients.

RESULTS

The pre-op ERCP group had a significantly higher incidence of ERCP related complications (odds ratio: 2.40, 95% confidence interval: 1.21-4.75).

CONCLUSIONS

The evidence provided by this meta-analysis suggests that both of these approaches would appear comparable. To fully address which would be the better approach would require an RCT as discussed above.

Comparison between intraoperative cholangiography and choledochoscopy for ductal clearance in laparoscopic CBD exploration: a prospective randomized study

BACKGROUND

Laparoscopic CBD exploration (LCBDE) is an accepted treatment modality for single stage management of CBD stones in fit patients. A transcholedochal approach is preferred in patients with a dilated CBD and large impacted stones in whom ductal clearance remains problematic. There are very few studies comparing intraoperative cholangiography (IOC) with choledochoscopy to determine ductal clearance in patients undergoing transcholedochal LCBDE. This series represents the first of those comparing the two from Asia.

METHODS

Between April 2009 and October 2012, 150 consecutive patients with CBD stones were enrolled in a prospective randomized study to undergo transcholedochal LCBDE on an intent-to-treat basis. Patients with CBD diameter of less than 9 mm on preoperative imaging were excluded from the study. Out of the 132 eligible patients, 65 patients underwent IOC (Group A), and 67 patients underwent intraoperative choledochoscopy (Group B) to determine CBD clearance.

RESULTS

There were no differences between the two groups in the demographic profile and the preoperative biochemical findings. There was no conversion to open procedures, and complete stone clearance was achieved in all the 132 cases. The mean CBD diameter and the mean number of CBD stones removed were comparable between the two groups. Mean operating time was 170 min in Group A and 140 min in Group B (p < 0.001). There was no difference in complications between the two groups. Nine patients in Group A (13.8%) showed non-passage of contrast into the duodenum on IOC which resolved after administration of i.v. glucagon, suggesting a transient spasm of sphincter of Oddi. Two patients (3%) showed a false-positive result on IOC which had to be resolved with choledochoscopy.

CONCLUSIONS

The present study showed that intraoperative choledochoscopy is better than IOC for determining ductal clearance after transcholedochal LCBDE and is less cumbersome and less time-consuming.

Management of choledocholithiasis in an emergency cohort undergoing laparoscopic cholecystectomy: a single-centre experience

INTRODUCTION

Minimally-invasive options for the management of choledocholithiasis in patients undergoing laparoscopic cholecystectomy include laparoscopic and endoscopic approaches. This study reviews the effectiveness of both approaches in an emergency setting.

METHODS

A retrospective chart review was performed for a cohort of patients who underwent laparoscopic cholecystectomy. Outcomes assessed were duct clearance, the number of procedures performed (NPP), length of stay (LOS) and complication rate.

RESULTS

A total of 182 patients who underwent emergency laparoscopic cholecystectomies received intervention for choledocholithiasis. The duct clearance rate was lower in the laparoscopic group, 63% versus 86% (P = 0.001). However, the median NPP was also lesser in the laparoscopic group, 1 (interquartile range (IQR) 1-2) versus 2 (IQR 2-2) (P < 0.001), as was the median LOS, 5 days (IQR 3-8) versus 7 days (IQR 6-10) (P = 0.009). Forty-eight laparoscopic endobiliary stents were attempted; stent deployment was successful in 37 patients. A larger proportion of patients with laparoscopic endobiliary stents had duct clearance by endoscopic retrograde cholangiopancreatography (ERCP) compared with those without, although this was not statistically significant (P = 0.208).

CONCLUSION

Laparoscopic clearance is not as effective as post-operative ERCP in an emergency cohort, but is associated with fewer procedures required and a shorter inpatient stay. Thus, laparoscopic clearance may still be an attractive option for surgeons especially where conditions are favourable during an emergency laparoscopic cholecystectomy.

Results of treatment of patients with gallstone disease and ductal calculi by single-stage laparoscopic cholecystectomy and bile duct exploration

INTRODUCTION

Choledocholithiasis is the most common cause of obstructive jaundice. Common bile duct stones are observed in 10-14% of patients diagnosed with gall bladder stones. In the case of gall bladder and common bile duct stones the procedure involves not only performing cholecystectomy but also removing the stones from bile ducts.

AIM

To compare the results of the treatment of patients with gallstone disease and ductal calculi by one-stage laparoscopic cholecystectomy and common bile duct exploration with two other methods: one-stage open cholecystectomy and common bile duct exploration, and a two-stage procedure involving endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy.

MATERIAL AND METHODS

Between 2004 and 2011 three groups of 100 patients were treated for obstructive jaundice caused by choledocholithiasis. The first group of 42 patients underwent ERCP followed by laparoscopic cholecystectomy. The second group of 23 patients underwent open cholecystectomy and common bile duct exploration, whereas the third group of 35 patients underwent laparoscopic cholecystectomy with common bile duct exploration. The data were analysed prospectively. The methods were compared according to complete execution, bile duct clearance and complication rate. Complications were analysed according to Clavien's Classification of Surgical Complications. The results were compared using the ANOVA statistical test and Student's t-test in Statistica. Value of p was calculated statistically. A p-value less than 0.05 (p < 0.05) signified that groups differed statistically, whereas a p-value more than 0.05 (p > 0.05) suggested no statistically significant differences between the groups.

RESULTS

The procedure could not be performed in 11.9% of patients in the first group and in 14.3% of patients in the third group. Residual stones were found in 13.5% of the patients in the first group, in 4.3% of the patients in the second group and in 6.7% of the patients in the third group. According to Clavien's classification of complications grade II and III, we can assign the range in the first group at 21.6% for grade II and 0% for grade III, in the second group at 21.4% and 3.6% and in the third group at 6.7% and 3.3% respectively.

CONCLUSIONS

The use of all three methods of treatment gives similar results. One-stage laparoscopic cholecystectomy with common bile duct exploration is after all the least invasive, safer and more effective procedure.

Endoscopic retrograde cholangiopancreatography in the treatment of intraoperatively demonstrated choledocholithiasis

INTRODUCTION

The aim of this study was to determine the efficacy and complications of postoperative endoscopic retrograde cholangiopancreatography (ERCP) in confirming and treating choledocholithiasis found at intraoperative cholangiography during laparoscopic cholecystectomy.

METHODS

Patients who had undergone ERCP following a cholecystectomy between 2008 and 2011 with an indication of intraoperative cholangiography findings consistent with choledocholithiasis were identified from a prospectively collected database of a single endoscopist. Deep biliary access rate, confirmation of choledocholithiasis, clearance rate of bile duct stones, delay between cholecystectomy and postoperative ERCP, and the complication rates following the procedure were analysed.

RESULTS

The median age of the 41 patients (16 male, 25 female) was 42 years (range: 18–82 years). Sixteen surgeons performed the operations with a median delay of 6 days (range: 1–103 days) between cholecystectomy and postoperative ERCP. Common bile duct access was achieved in 100% of the patients, with ERCP taking a median time of 16 minutes (range: 6–40 minutes). Initial ERCP confirmed the presence of a stone in 30 patients (73%) and successful stone removal occurred in 28 of these 30 patients (93%) during the first ERCP and in the remaining 2 on a subsequent ERCP. Following ERCP, two patients (4.9%) experienced extended hospital stays for four and eight days owing to complications, including one patient (2.4%) with mild acute pancreatitis.

CONCLUSIONS

This study demonstrates that postoperative ERCP is highly effective in both confirming and treating choledocholithiasis. However, there is a significant risk of short-term complications that must be taken into consideration when deciding management.

Long-term results of laparoscopic common bile duct exploration by choledochotomy for choledocholithiasis: 15-year experience from a single center

Purpose

The aim of this study is to assess the long-term results of laparoscopic common bile duct exploration (LCBDE) and validate its effectiveness as a primary treatment modality for CBD stone.

Methods

A retrospective review of the medical records of 157 patients who underwent LCBDE from 1997 to 2011 was conducted. All LCBDE were performed by choledochotomy. Clinical demographics, operative outcome, recurrence rate of CBD stones, and long-term bile duct complications were analyzed. The mean follow-up period was 51.9 months.

Results

LCBDE was completed in 152 patients (96.8%) and 5 patients (3.2%) had open conversion. The male/female ratio was 78/79 and mean age was 67.3 years. Stone clearance was successful in 149 of 152 patients (98.0%). Nonlethal complications were noted in 11 patients (7.2%), including bile leakage in 6 patients (3.9%). Recurrent CBD stones developed in 9 of 152 patients (5.9%). Preoperative endoscopic sphincterotomy (P = 0.492) and choledochotomy repair type (T-tube drainage vs. primary closure, P = 0.740) were not significantly related to stone recurrence. There were no signs of any type of biliary injury or stricture observed in any of the patients during the follow-up period.

Conclusion

LCBDE can be performed without increased risk of long-term complications such as bile duct stricture and recurrent CBD stones. LCBDE is a safe and effective treatment option for choledocholithiasis in terms of long-term outcome as well as short-term outcome.