Management of suspected common bile duct stones in children: role of selective intraoperative cholangiogram and endoscopic retrograde cholangiopancreatography

Clinical Utility of Definitive Diagnostic Tests for Choledocholithiasis in Pediatric Patients with Mild Gallstone Pancreatitis

BACKGROUND

Gallstone pancreatitis was historically considered a risk factor for choledocholithiasis (CD). However, recent studies of adult patients evidenced a weak association between gallstone pancreatitis and CD. The aim of this study was to analyze this association in pediatric patients.

METHODS

We conducted a retrospective study on patients with mild gallstone pancreatitis who underwent any definitive testing for CD (MRCP, ERCP, IOC), managed between March 2010 and September 2022. Patients were classified according to the presence or absence of risk factors for CD (total bilirubin ≥2 mg/dl; common bile duct >6 mm on ultrasound; and/or CD on ultrasound). We evaluated the diagnosis of CD on definitive testing in both groups and analyzed the predictive capacity of the presence of risk factors.

RESULTS

Eighty-four patients were included in the final analysis. Seventy-nine percent were females. The median age was 13 (4-17) years. Forty-seven (55.9%) patients had one or more risk factors. The definitive testing confirmed 13 (15.5%) cases of CD, 12 (25.5%) in the group of patients with risk factors and 1 (2.7%) in those without risk factors. The sensitivity, specificity, positive predictive value and negative predictive value of the presence of associated risk factors were 92.3, 50.7, 25.5 and 97.3%, respectively.

CONCLUSION

Pediatric patients with gallstone pancreatitis without associated risk factors have a very low incidence of CD. In these patients we suggest performing a laparoscopic cholecystectomy without intraoperative cholangiography or any other definitive test for CD.

LEVEL OF EVIDENCE

Level II, retrospective study.

Pediatric DUCT Score: A Highly Specific Predictive Model for Choledocholithiasis in Children

BACKGROUND

Current adult guidelines for the management of choledocholithiasis (CDL) may not be appropriate for children. We hypothesized adult preoperative predictive factors are not reliable for predicting CDL in children.

STUDY DESIGN

A multicenter retrospective cohort study was performed evaluating children (≤18 years of age) who underwent cholecystectomy for gallstone disease at 10 children's hospitals. Univariate and multivariable analyses were used to identify factors independently associated with CDL. Patients were stratified into risk groups demonstrating the presence of predictive factors for CDL. Statistical analyses were performed, and chi-square analyses were used with a significance of p < 0.05.

RESULTS

A total of 979 cholecystectomy patients were analyzed. The diagnosis of CDL was confirmed in 222 patients (22.7%) by magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, or intraoperative cholangiography. Three predictive factors were identified: (1) Dilated common bile duct ≥6 mm; (2) Ultrasound with Choledocholithiasis; and (3) Total bilirubin ≥1.8 mg/dL (pediatric DUCT criteria). Risk groups were based on the number of predictive factors: very high (3), high (2), intermediate (1), and low (0). The pediatric DUCT criteria demonstrated accuracies of >76%, specificity of >78%, and negative predictive values of >79%. Adult factors (elevated aspartate aminotransferase/alanine aminotransferase, pancreatitis, BMI, and age) did not independently predict CDL. Based on risk stratification, the high- and very-high-risk groups demonstrated higher predictive capacity for CDL.

CONCLUSIONS

Our study demonstrated that the pediatric DUCT criteria, incorporating common bile duct dilation, choledocholithiasis seen on ultrasound, and total bilirubin ≥1.8 mg/dL, highly predicts the presence of choledocholithiasis in children. Other adult preoperative factors are not predictive of common bile duct stone in children.

Development of a risk score for choledocholithiasis in pediatric patients

PURPOSE

The prevalence of gallstones in children has increased over the last years. Choledocholithiasis (CD) is present in up to 30% of the cases. There is a scarcity of studies on the management of choledocholithiasis in children. The aim of this study was to develop a score that would allow predicting accurately the risk of CD in children with gallstones and reduce the number of non-therapeutic ERCP.

MATERIALS AND METHODS

We conducted a retrospective study in children with gallstones and suspected CD seen between January 2010 and December 2019. The main outcome was the presence of CD confirmed by at least one of the following diagnostic tests: magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and/or intraoperative cholangiography (IOC). We developed a risk score based on the presence or absence of the following risk factors: acute biliary pancreatitis, ascending cholangitis, elevated liver function tests (AST, ALT, total bilirubin [TB, ≥ 2 mg/dl], conjugated bilirubin, gamma-glutamyl transpeptidase, and alkaline phosphatase), CD on ultrasound (US; this was considered predictive but not confirmatory of CD), and dilation of the common bile duct (> 6 mm) by US. The score was divided into three different categories: low risk (no risk factors), intermediate risk (one risk factor present), high risk (≥ 2 risk factors present or ascending cholangitis). Given the main goal of reducing the number of diagnostic ERCPs, a very-high-risk subgroup (3 risk factors present or ascending cholangitis) was identified.

RESULTS

We reviewed 133 patients with gallstones and suspected CD. In 56 (42.1%) patients, the presence of CD was confirmed by one or more of the definitive diagnostic tests (MRCP, ERCP, and IOC). The following variables were found to be the strongest predictors of CD: ascending cholangitis, TB ≥ 2 mg/dl, common bile duct > 6 mm, and the presence of CD by US. The positive predictive value for CD was 7.5% in the low-risk group (OR 0.06, P = < 0.001); 22.9% in the intermediate-risk group (OR 0.31, P = 0.007); 77.6% in the high-risk group (OR 20.14, P = < 0.001); and 95.7% in very-high-risk subgroup (OR 49.18, P = < 0.001).

CONCLUSION

The risk score proposed in this study predicts accurately the presence of CD in children with gallstones. It can serve as a helpful tool to triage the need for costly and complex studies in the workup of CD, particularly in centers with limited resources. Finally, due to its high specificity and positive predictive value (PPV), the use of the very-high-risk criteria would allow for an important decrease in the number of non-therapeutic ERCP.

Choledocholithiasis-a new clinical pathway

The incidence of cholecystectomy in children has increased considerably since the early 1990s. Management of gallbladder disease in children must include an awareness of choledocholithiasis treatment strategies. Both endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct exploration (open or laparoscopic) are accepted management techniques for choledocholithiasis. Laparoscopic cholecystectomy with preoperative or postoperative ERCP is at least a two-procedure process while cholecystectomy with laparoscopic common bile duct exploration (LCBDE) can provide definitive treatment in a single procedure under one anesthetic. Despite this, the trend over the last decade continues towards less LCBDE utilization in favor of ERCP. This trend has resulted in decreased familiarity with LCBDE by adult and pediatric surgeons and their trainees. Access to the necessary tools and education on the technical aspects can allow for successful single-stage treatment of choledocholithiasis by surgeons during laparoscopic cholecystectomy. This may include a pre-defined stepwise algorithm and understanding of all the equipment and resources necessary to perform a LCBDE. Ultimately, increased understanding of the equipment and procedural steps necessary for LCBDE will result in widened adoption of the technique and thus confer advantages to the patient such as decreased length of stay and fewer required anesthetics.

Utility of routine intraoperative cholangiogram during cholecystectomy in children: A nationwide analysis of outcomes and readmissions

PURPOSE

This study aims to determine postoperative outcomes and readmissions in pediatric cholecystectomy with routine intraoperative cholangiogram (IOC) utilization.

METHODS

The Nationwide Readmissions Database 2010-2014 was queried for all pediatric cholecystectomies. A propensity score-matched analysis (PSMA) with over 30 covariates was performed between cholecystectomy alone (CCY) versus those with routine IOC (CCY + IOC, no biliary obstruction, dilatation, or pancreatitis). χ² analysis or Mann-Whitney U were used for statistical analysis with p < 0.05 set as significant.

RESULTS

34,390 cholecystectomies were performed: 92% were laparoscopic, most were teenage females (75%, 15 years [13-17]) and did not undergo IOC (75%). Postoperative mortality rate was 0.1%. The PSMA cohort comprised of 1412 CCY and 1453 CCY + IOC. Patients with CCY alone had higher rates of 30-day (7% vs 5%), 1-year readmissions (13% vs 11%) and had higher rates of overall complications (22% vs 12%) compared with CCY + IOC, all p < 0.05. Although uncommon, bile duct injuries were more prevalent in CCY (2% vs 0%, p < 0.001), while there was no difference in readmissions for retained stones. Resource utilization was increased in CCY patients, likely due to increased complication rates.

CONCLUSION

This nationwide PSMA suggests pediatric CCY with routine IOC is associated with decreased readmissions, overall resource utilization, complications, and bile duct injuries.

TYPE OF STUDY

Retrospective Comparative Study.

LEVEL OF EVIDENCE

Level III.

[Biliary tract surgery in childhood]

In contrast to gallstones, which are increasingly diagnosed in children and adolescents, congenital or perinatally acquired malformations of the biliary tree are rare entities. The surgical treatment of these diseases frequently represents a technical challenge. For children with biliary atresia Kasai portoenterostomy is a therapeutic option in the first weeks of life. Most affected children, however, require a liver transplantation before they enter adulthood. Segmental dilatations of the bile duct carry the risk of ascending infections and malignant transformation. This requires early resection of the biliary tree and reconstruction with a bilioenteric anastomosis. While laparoscopic cholecystectomy has become the standard approach also for children, the value of minimally invasive procedures for more complex surgical procedures of the biliary tract has not yet been defined.

Pediatric Laparoscopic Common Bile Duct Exploration: An Opportunity to Decrease ERCP Complications

BACKGROUND

Laparoscopic intraoperative cholangiogram (IOC) with common bile duct exploration (CBDE) and endoscopic retrograde cholangiopancreatography (ERCP) are two therapeutic techniques for choledocholithiasis. The preferred technique is unclear.

MATERIALS AND METHODS

We identified subjects who underwent laparoscopic cholecystectomy (LC) and IOC/CBDE or ERCP from July 1, 2006, to December 31, 2016. We retrospectively reviewed 81 patients (≤ 18 y) who received these interventions for suspected choledocholithiasis. Main outcomes analyzed were success of intervention and complications.

RESULTS

Of the 81 patients, 21 ERCPs and three endoscopic ultrasounds (EUSs) were performed before LC. Eighteen of 21 (85.7%) patients had stones or sludge cleared by ERCP, whereas 3 (14.3%) had normal common bile ducts without evidence of stones. Five of 24 (20.8%) had significant post-ERCP complications. Seven of 24 (29.2%) had more than one admission. Sixty of 81 patients underwent LC with IOC ± CBDE. Twenty one of 60 (36.2%) were found to have abnormal IOC. Eight of 15 (53.3%) attempted laparoscopic CBDE were successful. Eleven of 21 (52.4%) patients with abnormal IOC had post-LC ERCP (10) and EUS (1). Patients admitted to the Pediatric Surgery service were more likely to undergo LC first than ERCP/EUS (OR 3.46, 95% CI 1.26 to 9.45, P = 0.016). Patients undergoing LC first had a shorter length of stay (mean LOS 5.13 d versus 4.07, median 5.0 versus 3.0 d, P-value < 0.05).

CONCLUSIONS

Successful and safe laparoscopic treatment of choledocholithiasis is possible in the pediatric patient. A laparoscopic-first approach to suspected choledocholithiasis may reduce the number of procedures needed in this patient population.

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.

Choledocholithiases in a child with Hemoglobin Evans [alpha2 62(E11) Val→Met]

We present the first description of choledocholithiases in a 10‐year‐old boy with Hemoglobin Evans. Although biliary stones are much less common in children than in adults, epigastric pain in children with known hemolytic status should alert the physician to the possibility of biliary colic.

Endoscopic retrograde cholangiography for pediatric choledocholithiasis: Assessing the need for endoscopic intervention

AIM: To assess pediatric patients for choledocholithiasis. We applied current adult guidelines to identify predictive factors in children.

METHODS: A single-center retrospective analysis was performed at a tertiary children’s hospital. We evaluated 44 consecutive pediatric patients who underwent endoscopic retrograde cholangiography (ERCP) for suspected choledocholithiasis. Patients were stratified into those with common bile duct stones (CBDS) at ERCP vs those that did not using the American Society of Gastrointestinal Endoscopy (ASGE) guidelines (Very Strong and Strong criteria) for suspected CBDS.

RESULTS: CBDS were identified in 84% at the time of ERCP. Abdominal ultrasound identified CBDS in 36% of patients. Conjugated bilirubin ≥ 0.5 mg/dL was an independent risk factor for CBDS (P = 0.003). The Very Strong (59.5%) and Strong (48.6%) ASGE criteria identified the majority of patients (P = 0.0001). A modified score using conjugated bilirubin had a higher sensitivity (81.2% vs 59.5%) and more likely to identify a stone than the standard criteria, odds ratio of 25.7 compared to 8.8. Alanine aminotransferase and gamma-glutamyl transferase values identified significant differences in a subset of patients with odds ratio of 4.1 and 3.25, respectively.

CONCLUSION: Current adult guidelines identified the majority of pediatric patients with CBDS, but specific pediatric guidelines may improve detection, thus decreasing risks and unnecessary procedures.

Timing of Cholecystectomy in Children With Biliary Pancreatitis

BACKGROUND

Biliary pancreatitis (BP) is common in adults and children. Current standard of care is to perform a cholecystectomy (CCE) to decrease the recurrence risk of pancreatitis. Controversy exists as to the timing of surgery, early versus delayed surgical intervention. Adult literature suggests a greater benefit of early CCE. Comparatively, there is limited pediatric literature as to the optimal timing of a CCE in children. We report a retrospective case series of children with BP who underwent early versus late CCE.

METHODS

A retrospective chart review was performed of children with BP for a period of 45 months. Reviewed information included patient demographics, timing of CCE, and the occurrence of adverse events preceding or following surgical intervention. Early CCE was defined as surgery during the index admission; late CCE was defined as surgery during a subsequent admission.

RESULTS

Nineteen children and adolescents (17 girls) were identified to have had BP with a subsequent CCE. Cholecystectomy was performed early in 9 patients with no adverse events. Ten patients had delayed surgery with 4 occurrences of adverse clinical events (recurrence of pancreatitis or biliary colic abdominal pain) while awaiting their CCE.

CONCLUSIONS

Adverse biliary-related events occur at a higher rate in children with mild BP who undergo a delayed CCE when compared to early CCE performance. Early CCE is safe to perform in children with mild BP.

Role of intraoperative cholangiography in patients whose biliary tree was evaluated preoperatively by magnetic resonance cholangiopancreatography

BACKGROUND

Routine performance of intraoperative cholangiography (IOC) during cholecystectomy is controversial. The aim of this study was to evaluate the role of IOC during cholecystectomy in addition to preoperative magnetic resonance cholangiopancreatography (MRCP) in our institution over a 12-year period.

METHODS

A total of 425 consecutive patients who underwent IOC during cholecystectomy were included in this study. MRCP was performed preoperatively for bile duct evaluation in all patients. When common bile duct (CBD) stones were detected, they were removed endoscopically before the operation. We estimated the results of IOC in terms of the success rate, the detection rate of anatomic abnormality of the biliary system, and the incidence of residual CBD stones.

RESULTS

MRCP preoperatively identified 6 (1.4 %) patients with abnormal biliary systems and 56 with CBD stones, which were endoscopically removed. The success rate of IOC was 93.8 % (399/425). Abnormalities of the biliary system were detected in 12 patients (12/399, 3.0 %) and CBD stones in 8 (8/399, 2.0 %). Of the eight patients with stones, seven had been examined by endoscopy preoperatively and found to have CBD stones. The detection rate of bile duct stones in patients with preoperative endoscopic removal of CBD stones (7/56, 12.5 %) was significantly higher than those with CBD stones first detected during IOC (1/365, 0.3 %) (p < 0.01). Moreover, no residual CBD stones were detected in patients who were operated on within fewer than 12 days from endoscopic treatment to the operation.

CONCLUSIONS

IOC is indicated even after preoperative sphincterotomy for CBD stones. In our study, it resulted in a 12.5 % incidence of persistent stones after sphincterotomy. IOC plays an additional role in detecting CBD stones and in revealing abnormalities of the biliary tree in patients whose biliary tree was preoperatively evaluated by MRCP.

Management of gallstone disease in children: a new protocol based on the experience of a single center

BACKGROUND/PURPOSE

Gallstones and cholelithiasis are being increasingly diagnosed in children owing to the widespread use of ultrasonography. The treatment of choice is cholecystectomy, and routine intraoperative cholangiography is recommended to explore the common bile duct. The objectives of this study were to describe our experience with the management of gallstone disease in childhood over the last 18 years and to propose an algorithm to guide the approach to cholelithiasis in children based on clinical and ultrasonographic findings.

METHODS

The data for this study were obtained by reviewing the records of all patients with gallstone disease treated between January 1994 and October 2011. The patients were divided into the following 5 groups based on their symptoms: group 1, asymptomatic; group 2, nonbiliary obstructive symptoms; group 3, acute cholecystitis symptoms; group 4, a history of biliary obstructive symptoms that were completely resolved by the time of surgery; and group 5, ongoing biliary obstructive symptoms. Patients were treated according to an algorithm based on their clinical, ultrasonographic, and endoscopic retrograde cholangiopancreatography (ERCP) findings.

RESULTS

A total of 223 patients were diagnosed with cholelithiasis, and comorbidities were present in 177 patients (79.3%). The most common comorbidities were hemolytic disorders in 139 patients (62.3%) and previous bariatric surgery in 16 (7.1%). Although symptoms were present in 134 patients (60.0%), cholecystectomy was performed for all patients with cholelithiasis, even if they were asymptomatic; the surgery was laparoscopic in 204 patients and open in 19. Fifty-six patients (25.1%) presented with complications as the first sign of cholelithiasis (eg, pancreatitis, choledocolithiasis, or acute calculous cholecystitis). Intraoperative cholangiography was indicated in 15 children, and it was positive in only 1 (0.4%) for whom ERCP was necessary to extract the stone after a laparoscopic cholecystectomy (LC). Preoperative ERCP was performed in 11 patients to extract the stones, and a hepaticojejunostomy was indicated in 2 patients. There were no injuries to the hepatic artery or common bile duct in our series.

CONCLUSIONS

Based on our experience, we can propose an algorithm to guide the approach to cholelithiasis in the pediatric population. The final conclusion is that LC results in limited postoperative complications in children with gallstones. When a diagnosis of choledocolithiasis or dilation of the choledocus is made, ERCP is necessary if obstructive symptoms persist either before or after an LC. Intraoperative cholangiography and laparoscopic common bile duct exploration are not mandatory.

Laparoscopic exploration of the common bile duct to relieve choledocholithiasis in children

PURPOSE

The optimal method of managing paediatric choledocholithiasis is controversial. Endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy are effective in adults; however, the long-term outcome in the paediatric population is unknown. We report our experience with laparoscopic common bile duct (CBD) exploration to relieve choledocholithiasis in children and propose a management algorithm.

METHODS

A retrospective chart review of 124 children, who underwent cholecystectomy over 5 years was conducted. Data collected included age at onset, duration of symptoms, length of stay, method of relieving choledocholithiasis and postoperative outcome.

RESULTS

Mean age was 12.5 years (range 10-14 years). 102 cholecystectomies were performed laparoscopically. Following intraoperative cholangiogram (IOC), choledocholithiasis was identified in eight patients. In three cases, the CBD was flushed with normal saline via a 5F ureteral catheter successfully relieving the obstruction. In three cases, a Dormia basket was used to break down the stone. Two cases required postoperative ERCP and sphincterotomy to successfully extract the stones. All children were symptom-free at follow-up with no complications reported to date.

CONCLUSION

Laparoscopic CBD exploration with Dormia basket or saline flushes to relieve choledocholithiasis is a safe and effective alternative in children. If unsuccessful, ERCP and sphincterotomy can be performed in centres with adequate resources and expertise.

Gallstone disease in children. Indian Pediatr. 2010;47:945-953. [PMID: 21149901 DOI: 10.1007/s13312-010-0159-2]

CONTEXT

little is known about the epidemiology of cholelithiasis in children. Cholelithiasis and choledocholithiasis were considered to be uncommon in infants and children but have been increasingly diagnosed in recent years due to wide- spread use of ultrasonography. However, there is not much of information from India and no consensus among Indian pediatricians and pediatric surgeons regarding management of gallstones in children. Hence, the purpose of this review is to increase awareness about the management of gallstones in children.

METHODS

extensive electronic (PubMed) literature search was made for this purpose and literature (original articles, clinical trials, case series, review articles) related to gallstones in children were reviewed.

CONCLUSIONS

the etiologies of cholelithiasis are hemolytic (20% -30%), other known etiology (40%-50%) such as total parenteral nutrition, ileal disease, congenital biliary diseases, and idiopathic (30-40 %). Spontaneous resolution of gallstones is frequent in infants and hence a period of observation is recommended even for choledocholithiasis. Children with gallstones can present with typical biliary symptoms (50%), nonspecific symptoms (25%), be asymptomatic (20%) or complicated (5% -10%). Cholecystectomy is useful in children with typical biliary symptoms but is not recommended in those with non-specific symptoms. Prophylactic cholecystectomy is recommended in children with hemolytic disorders.

Lessons learned from the first 109 laparoscopic cholecystectomies performed in a single pediatric surgery center

BACKGROUND

Laparoscopic cholecystectomy (LC) is a frequent operation in adults but is seldom performed in children. A retrospective review of 109 consecutive patients who underwent LC over an 11-year period was performed to see what lessons were learned from this experience.

METHODS

From January 1996 to January 2007, a total of 109 patients were referred to our unit to undergo LC. Nine adult patients were excluded from the analysis. The remaining 100 pediatric patients form the basis of this report. Isolated cholecystectomies were performed using a four-trocar technique, with a fifth trocar added for cases in which splenectomy was required. One patient with main bile duct dilatation at preoperative echography underwent peroperative cholangiography.

RESULTS

We recorded three anatomic anomalies (3%), two involving the bile duct and one the cystic artery. We recorded four minor problems during surgery: In one case there was failure of the tip of reusable scissors, and in three cases there was a small perforation of the gallbladder during the dissection step. We recorded four (4%) postoperative complications, which required redo surgery: one patient with bleeding from the cystic artery; one case of dislocation of clips positioned on the cystic duct; and two patients with lesions of the main bile duct that had not been detected during surgery. The treatment consisted in choledojejunostomy on postoperative day 7 in one case and suture of the choledocus on a stent positioned using endoscopic retrograde cholangiopancreatography on postoperative day 5 in the second case. Both biliary complications occurred in patients more than 14 years of age. We also recorded one umbilical granuloma.

CONCLUSIONS

LC is an effective procedure in children. On the basis of our experience, it seems that major complications can occur even with experienced surgeons, and they are more frequent in teenagers. Biliary or vascular anomalies of the gallbladder are encountered in about 3% of patients.

Simultaneous laparoendoscopic rendezvous for the treatment of cholecystocholedocholithiasis

BACKGROUND

Different approaches are available for the treatment of combined cholecystocholedocholithiasis including totally laparoscopic (TL) treatment, simultaneous laparoendoscopic treatment, and sequential treatments (ST) combining endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) with cholecystectomy. This review aimed to clarify the issue of the simultaneous laparoendoscopic rendezvous (RV).

METHODS

A careful analysis of papers was performed to determine the results, technical differences, limits, disadvantages, and advantages of RV compared with other options.

RESULTS

Data were collected from 27 papers concerning 795 patients. The overall effectiveness of RV was 92.3%. The morbidity rate was 5.1%, and the mortality rate was 0.37%. Almost all the authors were satisfied with the procedure. The authors' comparison to ST and TL showed that the advantages outweigh the disadvantages mostly related to logistical problems.

CONCLUSIONS

There is confusion concerning the definitions and techniques of RV due to differences in combining surgical and endoscopic steps of the procedure. The results are at least comparable with those of the other available approaches. The effectiveness of RV is greater with reciprocal implementation of surgical and endoscopic procedures. The morbidity and the risk of iatrogenic damage seem lower than with ERCP-ES and the risk of residual stones lower than with TL treatment. The RV procedure is safe and can sometimes be the preferable option, but collaboration between surgeon and endoscopist is mandatory.

Laparo-endoscopic “Rendezvous” to treat cholecysto-choledocolithiasis: Effective, safe and simplifies the endoscopist’s work

AIM: To investigate our clinical experience with combined laparo-endoscopic Rendezvous (RV) for the treatment of patients affected by gallstones and common bile duct (CBD) stones and especially to study the never evaluated opinion of the endoscopist concerning the difficulty of the intraoperative endoscopic procedure during the RV in comparison with standard endoscopic retrograde cholangio-pancreatography (ERCP).

METHODS: Eighty consecutive patients affected by cholecystolithiasis and diagnosed or suspected CBD stones were treated with a standardized “tailored” RV. The relevant technical features, the feasibility, the effectiveness in stone clearance, the safety but also the simple evaluation of difficulty and agreement of the endoscopist were analyzed with a questionnaire.

RESULTS: The feasibility was 97.5% and the effectiveness 100% concerning CBD clearance and solution of coexisting problems at the papilla. Minor morbidity was 3.3%, the operating time was prolonged by a mean of 14 min, the mean hospital stay was 3.8 d and only one stone’s recurrence occurred. The endoscopist evaluated the procedure to be simpler than standard ERCP-ES in 81.2% of the cases.

CONCLUSION: Simultaneous RV carries high effectiveness and safety at least comparable to those reported for other options. The endoscopist is very often satisfied with this approach because of the minimization of some steps of the endoscopic procedure and avoidance of relevant iatrogenic risk factors. If the mandatory collaboration between surgeons and endoscopists is guaranteed, this approach can often be preferable for the patient, the surgeon, the endoscopist and the hospital.

Is intra-operative cholangiography necessary during laparoscopic cholecystectomy? A multicentre rural experience from a developing world country

AIM: To evaluate the feasibility and safety of performing laparoscopic cholecystectomy (LC) in non-teaching rural hospitals of a developing country without intra-operative cholangiography (IOC). To evaluate the possibility of reduction of costs and hospital stay for patients undergoing LC.

METHODS: A prospective analysis of patients with symptomatic benign diseases of gall bladder undergoing LC in three non-teaching rural hospitals of Kashmir Valley from Jan 2001 to Jan 2007. The cohort represented a sample of patients requiring LC, aged 13 to 78 (mean 47.2) years. Main outcome parameters included mortality, complications, re-operation, conversion to open procedure without resorting to IOC, reduction in costs borne by the hospital, and the duration of hospital stay.

RESULTS: Twelve hundred and sixty-seven patients (976 females/291 males) underwent laparoscopic cholecystectomy. Twenty-three cases were converted to open procedures; 12 patients developed port site infection, nobody died because of the procedure. One patient had common bile duct (CBD) injury, 4 patients had biliary leak, and 4 patients had subcutaneous emphysema. One cholecystohepatic duct was detected and managed intraoperatively, 1 patient had retained CBD stones, while 1 patient had retained cystic duct stones. Incidental gallbladder malignancy was detected in 2 cases. No long-term complications were detected up to now.

CONCLUSION: LC can be performed safely even in non-teaching rural hospitals of a developing country provided proper equipment is available and the surgeons and other team members are well trained in the procedure. It is stressed that IOC is not essential to prevent biliary tract injuries and missed CBD stones. The costs to the patient and the hospital can be minimized by using reusable instruments, intracorporeal sutures, and condoms instead of titanium clips and endobags.

Acute biliary pancreatitis and cholecystolithiasis in a child: One time treatment with laparoendoscopic “Rendez-vous” procedure

Acute biliary pancreatitis (ABP) is rare in childhood and endoscopic sphincterotomy should be avoided in the child due to the risk of both early and late complications but, when necessary, the optimal timing between endoscopic procedure and cholecystectomy is still uncertain. A nine years old child with acute biliary pancreatitis underwent successfull laparo-endoscopic “Rendez-Vous” procedure in which endoscopic drainage of the common bile duct and laparoscopic cholecystectomy were performed simultaneously. This is the first case reported of laparo-endoscopic Rendez-Vous in a child. The excellent outcome of this patient and the review of the literature concerning other available options for the treatment of such cases suggest that this procedure offers great advantages, especially in children, of reducing the required number of treatments, the risk of ineffectiveness, the number of anaesthesia, the length of hospital stay and the risk of iatrogenic morbidity.