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Tunruttanakul S, Verasmith K, Patumanond J, Mingmalairak C. Development of a Predictive Model for Common Bile Duct Stones in Patients With Clinical Suspicion of Choledocholithiasis: A Cohort Study. Gastroenterology Res 2022; 15:240-252. [PMID: 36407811 PMCID: PMC9635785 DOI: 10.14740/gr1560] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/14/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Current choledocholithiasis guidelines heavily focus on patients with low or no risk, they may be inappropriate for populations with high rates of choledocholithiasis. We aimed to develop a predictive scoring model for choledocholithiasis in patients with relevant clinical manifestations. METHODS A multivariable predictive model development study based on a retrospective cohort of patients with clinical suspicion of choledocholithiasis was used in this study. The setting was a 700-bed public tertiary hospital. Participants were patients who had completed three reference tests (endoscopic retrograde cholangiography, magnetic resonance cholangiopancreatography, and intraoperative cholangiography) from January 2019 to June 2021. The model was developed using logistic regression analysis. Predictor selection was conducted using a backward stepwise approach. Three risk groups were considered. Model performance was evaluated by area under the receiver operating characteristic curve, calibration, classification measures, and decision curve analyses. RESULTS Six hundred twenty-one patients were included; the choledocholithiasis prevalence was 59.9%. The predictors were age > 55 years, pancreatitis, cholangitis, cirrhosis, alkaline phosphatase level of 125 - 250 or > 250 U/L, total bilirubin level > 4 mg/dL, common bile duct size > 6 mm, and common bile duct stone detection. Pancreatitis and cirrhosis each had a negative score. The sum of scores was -4.5 to 28.5. Patients were categorized into three risk groups: low-intermediate (score ≤ 5), intermediate (score 5.5 - 14.5), and high (score ≥ 15). Positive likelihood ratios were 0.16 and 3.47 in the low-intermediate and high-risk groups, respectively. The model had an area under the receiver operating characteristic curve of 0.80 (95% confidence interval: 0.76, 0.83) and was well-calibrated; it exhibited better statistical suitability to the high-prevalence population, compared to current guidelines. CONCLUSIONS Our scoring model had good predictive ability for choledocholithiasis in patients with relevant clinical manifestations. Consideration of other factors is necessary for clinical application, particularly regarding the availability of expert physicians and specialized equipment.
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Affiliation(s)
- Suppadech Tunruttanakul
- Department of Surgery, Sawanpracharak Hospital, Nakhon Sawan 60000, Thailand,Corresponding Author: Suppadech Tunruttanakul, Department of Surgery, Sawanpracharak Hospital, Muang, Nakhon Sawan 60000, Thailand.
| | | | - Jayanton Patumanond
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Chatchai Mingmalairak
- Department of Surgery, Faculty of Medicine, Thammasat University, Pathum Thani 10120, Thailand
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Panda N, Chang Y, Chokengarmwong N, Martinez M, Yu L, Fagenholz PJ, Kaafarani HA, King DR, Demoya MA, Velmahos GC, Dante Yeh D. Gallstone Pancreatitis and Choledocholithiasis: Using Imaging and Laboratory Trends to Predict the Likelihood of Persistent Stones at Cholangiography. World J Surg 2018; 42:3143-9. [DOI: 10.1007/s00268-018-4618-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Jovanovic P, Salkic NN, Zerem E. Artificial neural network predicts the need for therapeutic ERCP in patients with suspected choledocholithiasis. Gastrointest Endosc 2014; 80:260-8. [PMID: 24593947 DOI: 10.1016/j.gie.2014.01.023] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 01/09/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Selection of patients with the highest probability for therapeutic ERCP remains an important task in a clinical workup of patients with suspected choledocholithiasis (CDL). OBJECTIVE To determine whether an artificial neural network (ANN) model can improve the accuracy of selecting patients with a high probability of undergoing therapeutic ERCP among those with strong clinical suspicion of CDL and to compare it with our previously reported prediction model. DESIGN Prospective, observational study. SETTING Single, tertiary-care endoscopy center. PATIENTS Between January 2010 and September 2012, we prospectively recruited 291 consecutive patients who underwent ERCP after being referred to our center with firm suspicion for CDL. INTERVENTIONS Predictive scores for CDL based on a multivariate logistic regression model and ANN model. MAIN OUTCOME MEASUREMENTS The presence of common bile duct stones confirmed by ERCP. RESULTS There were 80.4% of patients with positive findings on ERCP. The area under the receiver-operating characteristic curve for our previously established multivariate logistic regression model was 0.787 (95% CI, 0.720-0.854; P < .001), whereas area under the curve for the ANN model was 0.884 (95% CI, 0.831-0.938; P < .001). The ANN model correctly classified 92.3% of patients with positive findings on ERCP and 69.6% patients with negative findings on ERCP. LIMITATIONS Only those variables believed to be related to the outcome of interest were included. The majority of patients in our sample had positive findings on ERCP. CONCLUSIONS An ANN model has better discriminant ability and accuracy than a multivariate logistic regression model in selecting patients for therapeutic ERCP.
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Affiliation(s)
- Predrag Jovanovic
- Department of Gastroenterology, University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina
| | - Nermin N Salkic
- Department of Gastroenterology, University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina
| | - Enver Zerem
- Department of Gastroenterology, University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina
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Abstract
BACKGROUND Between 10% to 18% of people undergoing cholecystectomy for gallstones have common bile duct stones. Treatment of the bile duct stones can be conducted as open cholecystectomy plus open common bile duct exploration or laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC + LCBDE) versus pre- or post-cholecystectomy endoscopic retrograde cholangiopancreatography (ERCP) in two stages, usually combined with either sphincterotomy (commonest) or sphincteroplasty (papillary dilatation) for common bile duct clearance. The benefits and harms of the different approaches are not known. OBJECTIVES We aimed to systematically review the benefits and harms of different approaches to the management of common bile duct stones. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7 of 12, 2013) in The Cochrane Library, MEDLINE (1946 to August 2013), EMBASE (1974 to August 2013), and Science Citation Index Expanded (1900 to August 2013). SELECTION CRITERIA We included all randomised clinical trials which compared the results from open surgery versus endoscopic clearance and laparoscopic surgery versus endoscopic clearance for common bile duct stones. DATA COLLECTION AND ANALYSIS Two review authors independently identified the trials for inclusion and independently extracted data. We calculated the odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI) using both fixed-effect and random-effects models meta-analyses, performed with Review Manager 5. MAIN RESULTS Sixteen randomised clinical trials with a total of 1758 randomised participants fulfilled the inclusion criteria of this review. Eight trials with 737 participants compared open surgical clearance with ERCP; five trials with 621 participants compared laparoscopic clearance with pre-operative ERCP; and two trials with 166 participants compared laparoscopic clearance with postoperative ERCP. One trial with 234 participants compared LCBDE with intra-operative ERCP. There were no trials of open or LCBDE versus ERCP in people without an intact gallbladder. All trials had a high risk of bias.There was no significant difference in the mortality between open surgery versus ERCP clearance (eight trials; 733 participants; 5/371 (1%) versus 10/358 (3%) OR 0.51;95% CI 0.18 to 1.44). Neither was there a significant difference in the morbidity between open surgery versus ERCP clearance (eight trials; 733 participants; 76/371 (20%) versus 67/358 (19%) OR 1.12; 95% CI 0.77 to 1.62). Participants in the open surgery group had significantly fewer retained stones compared with the ERCP group (seven trials; 609 participants; 20/313 (6%) versus 47/296 (16%) OR 0.36; 95% CI 0.21 to 0.62), P = 0.0002.There was no significant difference in the mortality between LC + LCBDE versus pre-operative ERCP +LC (five trials; 580 participants; 2/285 (0.7%) versus 3/295 (1%) OR 0.72; 95% CI 0.12 to 4.33). Neither was there was a significant difference in the morbidity between the two groups (five trials; 580 participants; 44/285 (15%) versus 37/295 (13%) OR 1.28; 95% CI 0.80 to 2.05). There was no significant difference between the two groups in the number of participants with retained stones (five trials; 580 participants; 24/285 (8%) versus 31/295 (11%) OR 0.79; 95% CI 0.45 to 1.39).There was only one trial assessing LC + LCBDE versus LC+intra-operative ERCP including 234 participants. There was no reported mortality in either of the groups. There was no significant difference in the morbidity, retained stones, procedure failure rates between the two intervention groups.Two trials assessed LC + LCBDE versus LC+post-operative ERCP. There was no reported mortality in either of the groups. There was no significant difference in the morbidity between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 13/81 (16%) versus 12/85 (14%) OR 1.16; 95% CI 0.50 to 2.72). There was a significant difference in the retained stones between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 7/81 (9%) versus 21/85 (25%) OR 0.28; 95% CI 0.11 to 0.72; P = 0.008.In total, seven trials including 746 participants compared single staged LC + LCBDE versus two-staged pre-operative ERCP + LC or LC + post-operative ERCP. There was no significant difference in the mortality between single and two-stage management (seven trials; 746 participants; 2/366 versus 3/380 OR 0.72; 95% CI 0.12 to 4.33). There was no a significant difference in the morbidity (seven trials; 746 participants; 57/366 (16%) versus 49/380 (13%) OR 1.25; 95% CI 0.83 to 1.89). There were significantly fewer retained stones in the single-stage group (31/366 participants; 8%) compared with the two-stage group (52/380 participants; 14%), but the difference was not statistically significantOR 0.59; 95% CI 0.37 to 0.94).There was no significant difference in the conversion rates of LCBDE to open surgery when compared with pre-operative, intra-operative, and postoperative ERCP groups. Meta-analysis of the outcomes duration of hospital stay, quality of life, and cost of the procedures could not be performed due to lack of data. AUTHORS' CONCLUSIONS Open bile duct surgery seems superior to ERCP in achieving common bile duct stone clearance based on the evidence available from the early endoscopy era. There is no significant difference in the mortality and morbidity between laparoscopic bile duct clearance and the endoscopic options. There is no significant reduction in the number of retained stones and failure rates in the laparoscopy groups compared with the pre-operative and intra-operative ERCP groups. There is no significant difference in the mortality, morbidity, retained stones, and failure rates between the single-stage laparoscopic bile duct clearance and two-stage endoscopic management. More randomised clinical trials without risks of systematic and random errors are necessary to confirm these findings.
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Affiliation(s)
- Bobby VM Dasari
- Mater Hospital/Belfast Health and Social Care TrustGeneral and Hepatobiliary Surgery15 BoulevardWellington SquareBelfastNorthern IrelandUKBT7 3LW
| | - Chuan Jin Tan
- Mater Hospital/Belfast Health and Social Care TrustGeneral and Hepatobiliary Surgery15 BoulevardWellington SquareBelfastNorthern IrelandUKBT7 3LW
| | - Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free Hospital,Rowland Hill StreetLondonUKNW3 2PF
| | - David J Martin
- Royal Prince Alfred, Concord & Strathfield Private Hospitals3 Everton Rd StrathfieldSydneyNSWAustralia2135
| | - Gareth Kirk
- Mater Hospital/Belfast Health and Social Care TrustGeneral and Hepatobiliary Surgery15 BoulevardWellington SquareBelfastNorthern IrelandUKBT7 3LW
| | - Lloyd McKie
- Mater Hospital/Belfast Health and Social Care TrustGeneral and Hepatobiliary Surgery15 BoulevardWellington SquareBelfastNorthern IrelandUKBT7 3LW
| | - Tom Diamond
- Mater Hospital/Belfast Health and Social Care TrustGeneral and Hepatobiliary Surgery15 BoulevardWellington SquareBelfastNorthern IrelandUKBT7 3LW
| | - Mark A Taylor
- Mater Hospital/Belfast Health and Social Care TrustGeneral and Hepatobiliary Surgery15 BoulevardWellington SquareBelfastNorthern IrelandUKBT7 3LW
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Abstract
BACKGROUND Between 10% to 18% of people undergoing cholecystectomy for gallstones have common bile duct stones. Treatment of the bile duct stones can be conducted as open cholecystectomy plus open common bile duct exploration or laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC + LCBDE) versus pre- or post-cholecystectomy endoscopic retrograde cholangiopancreatography (ERCP) in two stages, usually combined with either sphincterotomy (commonest) or sphincteroplasty (papillary dilatation) for common bile duct clearance. The benefits and harms of the different approaches are not known. OBJECTIVES We aimed to systematically review the benefits and harms of different approaches to the management of common bile duct stones. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7 of 12, 2013) in The Cochrane Library, MEDLINE (1946 to August 2013), EMBASE (1974 to August 2013), and Science Citation Index Expanded (1900 to August 2013). SELECTION CRITERIA We included all randomised clinical trials which compared the results from open surgery versus endoscopic clearance and laparoscopic surgery versus endoscopic clearance for common bile duct stones. DATA COLLECTION AND ANALYSIS Two review authors independently identified the trials for inclusion and independently extracted data. We calculated the odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI) using both fixed-effect and random-effects models meta-analyses, performed with Review Manager 5. MAIN RESULTS Sixteen randomised clinical trials with a total of 1758 randomised participants fulfilled the inclusion criteria of this review. Eight trials with 737 participants compared open surgical clearance with ERCP; five trials with 621 participants compared laparoscopic clearance with pre-operative ERCP; and two trials with 166 participants compared laparoscopic clearance with postoperative ERCP. One trial with 234 participants compared LCBDE with intra-operative ERCP. There were no trials of open or LCBDE versus ERCP in people without an intact gallbladder. All trials had a high risk of bias.There was no significant difference in the mortality between open surgery versus ERCP clearance (eight trials; 733 participants; 5/371 (1%) versus 10/358 (3%) OR 0.51;95% CI 0.18 to 1.44). Neither was there a significant difference in the morbidity between open surgery versus ERCP clearance (eight trials; 733 participants; 76/371 (20%) versus 67/358 (19%) OR 1.12; 95% CI 0.77 to 1.62). Participants in the open surgery group had significantly fewer retained stones compared with the ERCP group (seven trials; 609 participants; 20/313 (6%) versus 47/296 (16%) OR 0.36; 95% CI 0.21 to 0.62), P = 0.0002.There was no significant difference in the mortality between LC + LCBDE versus pre-operative ERCP +LC (five trials; 580 participants; 2/285 (0.7%) versus 3/295 (1%) OR 0.72; 95% CI 0.12 to 4.33). Neither was there was a significant difference in the morbidity between the two groups (five trials; 580 participants; 44/285 (15%) versus 37/295 (13%) OR 1.28; 95% CI 0.80 to 2.05). There was no significant difference between the two groups in the number of participants with retained stones (five trials; 580 participants; 24/285 (8%) versus 31/295 (11%) OR 0.79; 95% CI 0.45 to 1.39).There was only one trial assessing LC + LCBDE versus LC+intra-operative ERCP including 234 participants. There was no reported mortality in either of the groups. There was no significant difference in the morbidity, retained stones, procedure failure rates between the two intervention groups.Two trials assessed LC + LCBDE versus LC+post-operative ERCP. There was no reported mortality in either of the groups. There was no significant difference in the morbidity between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 13/81 (16%) versus 12/85 (14%) OR 1.16; 95% CI 0.50 to 2.72). There was a significant difference in the retained stones between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 7/81 (9%) versus 21/85 (25%) OR 0.28; 95% CI 0.11 to 0.72; P = 0.008.In total, seven trials including 746 participants compared single staged LC + LCBDE versus two-staged pre-operative ERCP + LC or LC + post-operative ERCP. There was no significant difference in the mortality between single and two-stage management (seven trials; 746 participants; 2/366 versus 3/380 OR 0.72; 95% CI 0.12 to 4.33). There was no a significant difference in the morbidity (seven trials; 746 participants; 57/366 (16%) versus 49/380 (13%) OR 1.25; 95% CI 0.83 to 1.89). There were significantly fewer retained stones in the single-stage group (31/366 participants; 8%) compared with the two-stage group (52/380 participants; 14%), but the difference was not statistically significantOR 0.59; 95% CI 0.37 to 0.94).There was no significant difference in the conversion rates of LCBDE to open surgery when compared with pre-operative, intra-operative, and postoperative ERCP groups. Meta-analysis of the outcomes duration of hospital stay, quality of life, and cost of the procedures could not be performed due to lack of data. AUTHORS' CONCLUSIONS Open bile duct surgery seems superior to ERCP in achieving common bile duct stone clearance based on the evidence available from the early endoscopy era. There is no significant difference in the mortality and morbidity between laparoscopic bile duct clearance and the endoscopic options. There is no significant reduction in the number of retained stones and failure rates in the laparoscopy groups compared with the pre-operative and intra-operative ERCP groups. There is no significant difference in the mortality, morbidity, retained stones, and failure rates between the single-stage laparoscopic bile duct clearance and two-stage endoscopic management. More randomised clinical trials without risks of systematic and random errors are necessary to confirm these findings.
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Affiliation(s)
- Bobby V M Dasari
- General and Hepatobiliary Surgery, Mater Hospital/Belfast Health and Social Care Trust, 15 Boulevard, Wellington Square, Belfast, Northern Ireland, UK, BT7 3LW
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Videhult P, Sandblom G, Rudberg C, Rasmussen IC. Are liver function tests, pancreatitis and cholecystitis predictors of common bile duct stones? Results of a prospective, population-based, cohort study of 1171 patients undergoing cholecystectomy. HPB (Oxford) 2011; 13:519-27. [PMID: 21762294 PMCID: PMC3163273 DOI: 10.1111/j.1477-2574.2011.00317.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The purpose of this study was to explore the accuracy of elevated liver function values, age, gender, pancreatitis and cholecystitis as predictors of common bile duct stones (CBDS). METHODS All patients operated on for gallstone disease over a period of 3 years in a Swedish county of 302,564 citizens were registered prospectively. Intraoperative cholangiography (IOC) was used to detect CBDS. RESULTS A total of 1171 patients were registered; 95% of these patients underwent IOC. Common bile duct stones were found in 42% of patients with elevated liver function values, 20% of patients with a history of pancreatitis and 9% of patients with cholecystitis. The presence of CBDS was significantly predicted by elevated liver function values, but not by age, gender, history of acute pancreatitis or cholecystitis. A total of 93% of patients with normal liver function tests had a normal IOC. The best agreement between elevated liver function values and CBDS was seen in patients undergoing elective surgery without a history of acute pancreatitis or cholecystitis. CONCLUSIONS Although alkaline phosphatase (ALP) and bilirubin levels represented the most reliable predictors of CBDS, false positive and false negative values were common, especially in patients with a history of cholecystitis or pancreatitis, which indicates that other mechanisms were responsible for elevated liver function values in these patients.
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Affiliation(s)
| | - Gabriel Sandblom
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Huddinge HospitalStockholm
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van Geenen EJ, van der Peet DL, Mulder CJ, Cuesta MA, Bruno MJ. Recurrent acute biliary pancreatitis: the protective role of cholecystectomy and endoscopic sphincterotomy. Surg Endosc 2009; 23:950-6. [PMID: 19266236 DOI: 10.1007/s00464-009-0339-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2008] [Revised: 12/19/2008] [Accepted: 01/01/2009] [Indexed: 10/21/2022]
Abstract
BACKGROUND Recurrent attacks of acute biliary pancreatitis (RABP) are prevented by (laparoscopic) cholecystectomy. Since the introduction of endoscopic retrograde cholangiopancreaticography (ERCP), several series have described a similar reduction of RABP after endoscopic sphincterotomy (ES). This report discusses the different treatment options for preventing RABP including conservative treatment, cholecystectomy, ES, and combinations of these options as well as their respective timing. METHODS A search in PubMed for observational studies and clinical (comparative) trials published in the English language was performed on the subject of recurrent acute biliary pancreatitis and other gallstone complications after an initial attack of acute pancreatitis. RESULT Cholecystectomy and ES both are superior to conservative treatment in reducing the incidence of RABP. Cholecystectomy provides additional protection for gallstone-related complications and mortality. Observational studies indicate that cholecystectomy combined with ES is the most effective treatment for reducing the incidence of RABP attacks. CONCLUSION From the literature data it can be concluded that ES is as effective in reducing RABP as cholecystectomy but inferior in reducing mortality and overall morbidity. The combination of ES and cholecystectomy seems superior to either of the treatment methods alone. A prospective randomized clinical trial comparing ES plus cholecystectomy with cholecystectomy alone is needed.
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Abstract
BACKGROUND 10% to 18% of patients undergoing cholecystectomy for gallstones have common bile duct (CBD) stones. Treatment options for these stones include pre- or post-operative endoscopic retrograde cholangiopancreatography (ERCP) or open or laparoscopic surgery. OBJECTIVES To systematically review the management of CBD stones by four approaches: (1) ERCP versus open surgical bile duct clearance. (2) Pre-operative ERCP versus laparoscopic bile duct clearance. (3) Post-operative ERCP versus laparoscopic bile duct clearance. (4) ERCP versus laparoscopic bile duct clearance in patients with previous cholecystectomy. SEARCH STRATEGY We systematically searched key relevant electronic databases, bibliographies of relevant papers, and abstracts of relevant subspecialty meetings until November 2005. SELECTION CRITERIA The quality of included trials was assessed by adequacy of allocation sequence generation, allocation concealment, blinding, and follow-up. DATA COLLECTION AND ANALYSIS Published and unpublished data relevant to 12 predefined outcome measures were used to conduct fixed- and random-effects models meta-analyses, with exploration of heterogeneity and use of sensitivity and subgroup analysis where required. MAIN RESULTS Thirteen trials randomised 1351 patients. Eight trials (n = 760) compared ERCP with open surgical clearance, three (n = 425) compared pre-operative ERCP with laparoscopic clearance, and two (n = 166) compared post-operative ERCP with laparoscopic clearance. There were no trials of ERCP versus laparoscopic clearance in patients without an intact gallbladder. Methodology was considered adequate in at least two of three assessable fields in ten trials. A significantly increased number of total procedures (including for complications) per patient was seen in the ERCP arms in all three comparisons with weighted mean differences of 0.62 (95% CI 0.15 to 1.09), 0.96 (95% CI 0.96 to 0.96), and 1.09 (95% CI 0.93 to 1.24), respectively. ERCP was less successful than open surgery in CBD stone clearance (Peto OR 2.89, 95% CI 1.81 to 4.61) with a tendency towards higher mortality (risk difference 1%, 95% CI -1% to 4%). Laparoscopic CBD stone clearance was as efficient as pre- (Peto OR 1.00, CI 0.53 to 1.80) and post-operative ERCP (OR 2.27, 95% CI 0.37 to 13.9) and with no significant difference in morbidity and mortality. Laparoscopic trials universally reported shorter hospital stays in surgical arms. Insufficient data were reported for cost analysis. AUTHORS' CONCLUSIONS In the era of open cholecystectomy, open bile duct surgery was superior to ERCP in achieving CBD stone clearance. In the laparoscopic era, data are close to excluding a significant difference between laparoscopic and ERCP clearance of CBD stones. The use of ERCP necessitates increased number of procedures per patient.
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Affiliation(s)
- D J Martin
- Copenhagen Trial Unit, Dept 71 02, Cochrane Hepato-Biliary Group, Blegdamsvej 9, Copenhagen Ø, DK-2100, DENMARK.
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Abstract
Bile duct stones (BDS) are often suspected on history and clinical examination alone but symptoms may be variable ranging from asymptomatic to complications such as biliary colic, pancreatitis, jaundice or cholangitis. The majority of BDS can be diagnosed by transabdominal ultrasound, computed tomography, endoscopic ultrasound or magnetic resonance cholangiography prior to endoscopic or laparoscopic removal. Approximately 90% of BDS can be removed following endoscopic retrograde cholangiography (ERC)+sphincterotomy. Most of the remaining stones can be removed using mechanical lithotripsy. Patients with uncorrected coagulopathies may be treated with ERC+pneumatic dilatation of the sphincter of Oddi. Shockwave lithotripsy (intraductal and extracorporeal) and laser lithotripsy have also been used to fragment large bile duct stones prior to endoscopic removal. The role of medical therapy in treatment of BDS is currently uncertain. This review focuses on the clinical presentation, investigation and current management of BDS.
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Affiliation(s)
- Grant R Caddy
- Department of Gastroenterology, Ulster Hospital, Dundonald, Belfast, Northern Ireland, UK.
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Snow LL, Weinstein LS, Hannon JK, Lane DR. Evaluation of operative cholangiography in 2043 patients undergoing laparoscopic cholecystectomy: a case for the selective operative cholangiogram. Surg Endosc 2001; 15:14-20. [PMID: 11178754 DOI: 10.1007/s004640000311] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND There is still some controversy over whether to use laparoscopic operative cholangiograms routinely (RLOC) or selectively (SLOC). Due to their high cost as well as other issues, in March 1997 we converted from RLOC to SLOC. The purpose of this study was to validate that decision. METHODS The results of 2043 laparoscopic cholecystectomies (LC) were compiled and analyzed. The results of RLOC in 1556 patients undergoing LC from March 1990 through February 1997 were compared to the results of SLOC in 16 patients undergoing LC from March 1989 through February 1990 and 471 patients undergoing LC from March 1997 through December 1998. The literature was reviewed and data were compiled. Reasons that are typically given for operative cholangiograms (OC) were collected and scrutinized. Finally, cost surveys for RLOC and related procedures were obtained. RESULTS Overall, laparoscopic operative cholangiogram (LOC) was attempted in 1661 patients and was successful in 1656 cases (99.7%). Bile duct stones (BDS) were evident in 166 patients. Laparoscopic bile duct exploration (LBDE) was attempted in all cases. None were referred for preoperative endoscopic retrograde cholangiopancreatography (ERCP). In the RLOC group, evidence of BDS was observed in 136 patients (9%). Forty-two were unsuspected (2.8%) and five were false positive (0.3%). In a collection of other RLOC studies, the average rate of unsuspected BDS was 2.9%, while the average rate of false positive cholangiograms was 1.6%. In the SLOC group, LOC was indicated in 139 of 487 patients (28.6%). None of the patients who did not have a LOC developed symptomatic residual BDS in < or = 11 years of follow-up. In a large collection of other SLOC studies, the rate of symptomatic residual BDS was 0.3%. A cost survey in February 1997 revealed that the average minimum global charge (MGC) for an OC was $1283.21; for a transcystic duct LBDE it was $1055.10, and for a transcholedochal LBDE it was $3263.61 [corrected]. The MGC for an ERCP with papillotomy was $4303.00. Thus, to avoid one patient with symptomatic residual BDS, 354 unnecessary procedures (333 RLOC, 18 LBDE, and three postoperative ERCP) costing $473,927.52 would be performed. There were no false negatives, bile duct injuries, or other complications attributable to RLOC or SLOC. CONCLUSIONS The increased morbidity and cost of RLOC to avoid symptomatic residual BDS is not justified. All other reasons given for RLOC are either flawed or indicate that the procedure can be safely employed selectively. SLOC is an effective method of verifying suspected BDS and is safer and less expensive than RLOC.
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Affiliation(s)
- L L Snow
- Department of Surgery, University of South Alabama College of Medicine, Mobile 36607, USA
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11
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Abstract
Intraoperative ultrasonography during abdominal surgery became widespread by availability of high-frequency, high-resolution transducers. It's usefulness has particularly been proven in biliar and gastrointestinal surgery. Our objective was to examine the method in laparoscopic cholecystectomy and in laparoscopic staging of malignancies of the upper gastrointestinal tract as well. Lapaoscopic ultrasound (LUS) examination was performed in 567 patients operated on because of biliary stones and in 12 patients with carcinoma in the upper part of the gastrointestinal tract. In accordance to the known criteria endoscopic retrograde cholangiopancreatography (ERCP) was performed in 89 patients, and additionally, ERCP was performed in 58 patients because of dilated common bile duct. Choledochal stones were demonstrated in 72 of the 147 patients. Laparoscopic ultrasonography demonstrated preoperatively undetected bile duct stones in 18 of these patients (12%). In 294 other patients without any criteria of bile duct stones, laparoscopic ultrasonography demonstrated bile duct stones in 11 patients (4%). Laparoscopic ultrasonography in 12 patients with proximal gastrointestinal malignancies demonstrated inoperability in all of the patients. Laparotomy could thereby be avoided. LUS examination is an ideal operative tool as it is safe, reproducible and requires no special patient preparation or positioning. The method of imaging is therefore justified for patients undergoing laparoscopic surgery because of biliary stones and gastrointestinal surgery.
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Affiliation(s)
- A K Olsen
- Surgical Department, Central Hospital of Rogaland, PO Box 8100, N-8003, Stavanger, Norway
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Abstract
BACKGROUND The role of preoperative ERCP and endoscopic sphincterotomy (ES) in the diagnosis and treatment of suspected common bile duct stones (CBDS) in the laparoscopic age is controversial. The preoperative diagnosis of CBDS by ERCP and the removal of CBDS by ES are advantageous because of technical difficulties in performing laparoscopic exploration of the common bile duct. Approximately 50% of preoperative ERCP examinations are normal, however. The noninvasive diagnosis of CBDS has assumed new importance, but it has proved to be an elusive goal. Neural networks are a form of artificial computer intelligence that have been used successfully to interpret ECGs and to diagnose myocardial infarcts. The purpose of this study was to determine whether a neural network could be trained to predict CBDS accurately in patients at high risk of having duct stones. STUDY DESIGN We trained a back-propagation neural network to predict the presence of CBDS. Retrospective data from patients who had a cholecystectomy and either a preoperative ERCP or intraoperative cholangiogram were used to build the network, and it was tested using unseen data. RESULTS One hundred forty patients were used to train the network, and 16 patients were used to test it. The trained network was able to predict CBDS in 100% of the patients in both the training and test sets. CONCLUSIONS Screening of high-risk patients for CBDS by neural network analysis is highly accurate. This promising new, noninvasive, and inexpensive technique can potentially decrease the need for preoperative ERCP by 50%, but additional prospective evaluation is indicated.
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Affiliation(s)
- R Golub
- Department of Surgery, The New York Flushing Hospital, 11355, USA
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Fiore NF, Ledniczky G, Wiebke EA, Broadie TA, Pruitt AL, Goulet RJ, Grosfeld JL, Canal DF. An analysis of perioperative cholangiography in one thousand laparoscopic cholecystectomies. Surgery 1997; 122:817-21; discussion 821-3. [PMID: 9347861 DOI: 10.1016/s0039-6060(97)90092-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND We undertook this retrospective study to ascertain the proper role of perioperative cholangiography in the management of 1002 patients undergoing laparoscopic cholecystectomy for symptomatic cholelithiasis. METHODS Nine hundred forty-one patients were categorized as being at high or low risk for choledocholithiasis according to the presence or absence of jaundice, pancreatitis, elevated bilirubin, alkaline phosphatase, serum glutamic-oxaloacetic transaminase, or radiographic evidence of common bile duct stones (CBDSs). RESULTS Intraoperative cholangiography (IOCG) and preoperative endoscopic retrograde cholangiopancreatography (ERCP) were equivalent in the detection of CBDSs, and laparoscopic common bile duct exploration (CBDE) was successful in 12 of the 21 patients (57%) in whom it was attempted. The ducts of the other 52 patients with CBDSs were successfully cleared by preoperative or postoperative ERCP. CONCLUSIONS Laparoscopic IOCG is successful in detecting CBDS in high-risk patients and half of these ducts can be cleared laparoscopically. The incidence of CBDS in low-risk patients is 1.7%, a risk that does not warrant routine cholangiography. These data suggest ERCP should be reserved for those at-risk individuals in whom IOCG or laparoscopic duct clearance has been unsuccessful.
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Affiliation(s)
- N F Fiore
- Department of Surgery, Indiana University School of Medicine, Indianapolis, USA
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Abstract
INTRODUCTION The results of laparoscopic cholecystectomy performed as an outpatient procedure were evaluated in a prospective study. METHODS Initially, only well motivated and healthy patients were offered outpatient laparoscopic cholecystectomy. After 50 procedures, all patients referred to the hospital, except those with American Society of Anesthesiologists (ASA) grade IV and those living alone, were included. Some 200 procedures were studied. RESULTS Twelve patients (6 per cent) were admitted, and 188 (94 per cent) were discharged 4-8 h after operation. Fifteen patients (8 per cent) who had early discharge were readmitted, nine with complications; in six no complications were documented. The frequency of minor complications was 2 per cent and of major complications 5 per cent. Some 173 patients who had successful outpatient laparoscopic cholecystectomy completed a questionnaire: 164 (95 per cent) characterized their experience as excellent, five (3 per cent) as good, two (1 per cent) as intermediate and two (1 per cent) as unacceptable. DISCUSSION This high achievement of day-case treatment, even in patients with ASA grade III, is explained by a new anaesthetic regimen together with good surgical technique and close follow-up.
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Affiliation(s)
- O Mjåland
- Department of Surgery, Ullevaal University Hospital, Oslo, Norway
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Søndenaa K, Nesvik I, Solhaug JH, Søreide O. Randomization to surgery or observation in patients with symptomatic gallbladder stone disease. The problem of evidence-based medicine in clinical practice. Scand J Gastroenterol 1997; 32:611-6. [PMID: 9200296 DOI: 10.3109/00365529709025108] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The description and understanding of gallbladder stone disease in the medical literature are difficult because an assessment of the natural course of this symptomatic disease, with separation of patients in strictly defined groups, is generally lacking. METHOD A multicenter study was carried out with patients randomized to either surgery or conservative, expectant treatment to examine optimal treatment and natural history in well-defined groups of symptomatic gallbladder stone disease with pain, episodes only (study group 1) or acute cholecystitis (study group 2). The patients were between 18 and 80 years of age and had right upper quadrant or midline epigastric pain and ultrasonographic evidence of gallbladder stone, with or without acute cholecystitis. Medical treatment was ordinated on the basis of signs and symptom severity. Patients randomized to surgery were placed on the hospital's waiting list and electively operated on with cholecystectomy as soon as conveniently possible. Preliminary results of follow-up are based on questionnaires mailed at regular intervals and consultations if required by the patients' symptoms. Quality of life and freedom from pain are study end points for evaluation. RESULTS Five hundred and one patients were considered for the study, 318 patients (63.5%) belonging to group 1 and 183 (36.5%) to group 2. One hundred and eighty-four patients (36.7%) were randomized, 120 (24%) in group 1 and 64 (12.7%) in group 2. Three hundred and seventeen patients (63.3%), with an equal proportion from each study group, were excluded, the largest number of patients because of incapacitating pain or serious presenting symptoms (26%). More women (81%) than men (19%) had pain alone (group 1), but the sex ratio was reduced, 56% women and 44% men, in patients with acute cholecystitis (group 2), with a highly significant difference (P = < 0.001) between the two groups. A significant difference in patient withdrawal from randomized treatment was registered, with 24% from observation and 12% from surgery (P = 0.032), but with an equal distribution in the two study groups. CONCLUSIONS A randomized trial of this nature is feasible but extremely difficult to perform because of the heterogeneous nature of gallbladder stone disease, leading to exclusion of many patients and difficulties in measuring and evaluating outcome variables.
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Affiliation(s)
- K Søndenaa
- Dept. of Surgery, Haukeland Hospital, Bergen, Norway
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Krähenbühl L, Büchler MW. Invited commentary to: “Laparoscopic cholecystectomy—How to diagnose common bile duct stones?”. ACTA ACUST UNITED AC 1996. [DOI: 10.1007/bf02602614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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