Management of choledocholithiasis in the time of laparoscopic cholecystectomy

Primary closure of the common bile duct in the treatment of choledocholithiasis

Surgical institutions equipped to apply endoscopic retrograde cholangiopancreatography with papillotomy do not treat non-complicated choledocholithiasis in a surgical way any more. However, those institutions which have not yet started to perform cholangiopancreatography apply surgical treatment of choledocholithiasis, and therefore, choledochography is still an option to end the exploration of choledochus with or without the concrement removal. Since cholangiopancreatography has not become a routine treatment in our institution, we have tried to determine the role of the primary closure of the choledochus in the treatment of choledocholithiasis as well as the indications and contraindications for its application.

Predição da coledocolitíase pela associação de indicadores clínicos e laboratoriais em dois momentos do pré-operatório da colecistectomia

OBJETIVO: O propósito deste estudo foi determinar a probabilidade de ocorrência de coledocolitíase através do estudo da associação de indicadores clínicos e laboratoriais desta doença em dois momentos do pré-operatório de colecistectomia. MÉTODO: Entre março de 2001 e março de 2002, 48 pacientes consecutivos com colelitíase foram submetidos a colecistectomia e colangiografia intra-operatória (CIO). Os pacientes foram divididos em dois grupos, sendo o grupo A constituído por 13 pacientes com coledocolitíase e o grupo B por 35 pacientes sem esta doença. Os pacientes foram investigados quanto aos indicadores clínicos e laboratoriais da coledocolitíase, analisados em dois períodos, tomando como ponto de corte as 48 horas que precederam a cirurgia. Posteriormente, estes indicadores pré-operatórios foram associados na equação da regressão logística em diferentes combinações. RESULTADOS: Utilizando a equação da regressão logística, constatou-se que a associação de dois indicadores clínicos em ambos os períodos (icterícia e sinal de Murphy) e dois laboratoriais ( nível de corte da gama glutamil transpeptidase e bilirrubina direta 48 horas antes da cirurgia) foi a mais adequada para a predição da coledocolitíase. Os valores obtidos por esta equação mostraram concordância com os grupos A e B, de 95,6%, e discordância de 4,4% (p= 0,0000007 e k = 0,89). Esta equação mostrou sensibilidade de 92,3%, especificidade de 97,0%, valor preditivo positivo de 92,3% e valor preditivo negativo de 97%. Estes valores foram próximos aos obtidos pela CIO, que mostrou concordância com os grupos estudados de 95,8%, e discordância de 4,2% (k = 0,90). CONCLUSÃO: Considerando os resultados obtidos, recomenda-se a associação de indicadores da coledocolitíase na equação da regressão logística para estabelecer a probabilidade de ocorrer coledocolitíase associada à colelitíase. A utilização desta equação pode orientar melhor a conduta diagnóstica e terapêutica nesta doença.

Detection of common bile duct stones before laparoscopic cholecystectomy. Evaluation with MR cholangiography

PURPOSE

To assess the diagnostic value of MR cholangiography (MRC) for detecting common bile duct (CBD) stones in candidates for laparoscopic cholecystectomy (LC).

MATERIAL AND METHODS

A series of 95 selected patients with gallstones and suspected CBD lithiasis (abnormal serum liver tests and/or CBD size > or = 6.5 mm at US) were referred to our institution for MRC, before LC. MRC was performed on a 0.5 T magnet through a non-breath-hold, respiratory-triggered, fat-suppressed, thin-slab, heavily T2-weighted fast spin-echo sequence and through a breath-hold, thick-slab, single-shot T2-weighted sequence in the coronal plane. Axial T1- and T2-weighted sequences were first obtained. Two observers in conference reviewed source images and maximum intensity projections to determine the presence or absence of choledocholithiasis. MR findings were compared with endoscopic retrograde cholangiography and intraoperative cholangiography (IOC); IOC was always performed during LC.

RESULTS

CBD calculi (single or multiple) were identified in 41 out of 95 patients (43%). Two false-positive and 4 false-negative cases were found on MRC. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of MRC for choledocholithiasis were 90%, 96%, 94%, 95%, and 93%, respectively.

CONCLUSION

MRC is a highly effective diagnostic modality for evaluation of patients with risk factors for CBD stones prior to LC.

Gallstone cholangitis: a 10-year experience of combined endoscopic and laparoscopic treatment

BACKGROUND

To date, no procedure has yet been identified as the gold standard for the treatment of gallstone cholangitis in the laparoscopic era.

METHODS

The data of 109 consecutive patients with acute cholangitis were prospectively entered into a computerized database. All patients were managed according to a standard protocol. The main treatments were endoscopic retrograde cholangiography (ERC) combined with endoscopic sphincterotomy (ES), followed by interval laparoscopic cholecystectomy (LC). Patients in whom ERC or endoscopic stone clearance failed were managed by emergency open common bile duct exploration. LC was performed with a standardized four-cannula technique. The mean duration of surgery, conversion rate, and postoperative outcome of these patients were evaluated.

RESULTS

ERC was successful in 103 patients (94.5%). In five of these patients (4.8%), no bile duct stones were found. The 98 patients (95.2%) with common bile duct stones were referred for ES. The bile duct stones were successfully removed after ES in 93 cases (94.9%). The overall failure rate of ERC and ES for choledocholithiasis was 10.1%. Self-limiting pancreatitis occurred in four patients (4.3%). Overall, two of the 109 patients died (1.8%). After ES, 81 patients underwent LC. LC was performed successfully in 74 patients (91.3%). Conversion to open surgery was required in seven patients (8.7%). The morbidity rate after cholecystectomy was 7.4%; the morbidity rate after open bile duct exploration was 36.4% (p<0.05). Fifteen patients were managed conservatively after initial endoscopic management of their cholangitis. The overall incidence of recurrent biliary symptoms was significantly higher among patients with gallbladder in place than for patients who underwent cholecystectomy (38.5% vs 1.5%, p<0.001).

CONCLUSIONS

ES followed by LC is a safe and effective approach for the management of gallstone cholangitis; cholecystectomy should be performed in patients with gallstone cholangitis unless the operative risk is extremely high. These high operative risk patients and those who refuse surgery after ES should be warned that they are at high risk for recurrent biliary symptoms.

Laparoscopic transcystic bile duct stenting in the management of common bile duct stones

BACKGROUND

The management of patients with common bile duct stones associated with stones in the gall bladder remains controversial.

METHODS

Over the three-year period from 1996 to 1999, patients with cholelithiasis and known choledocholithiasis, or choledocholithiasis found at laparoscopic cholecystectomy, were initially treated by placing a stent across the sphincter of Oddi. The stent was pushed along a guide wire through the cystic duct and then down the common bile duct, before the cystic duct was closed. Subsequently, the stent was used to facilitate performance of a needle knife endoscopic sphincterotomy. The stent was then removed, a cholangiography was performed and the common bile duct was cleared. Patients with persistent jaundice usually had a preoperative endoscopic retrograde cholangio-pancreatography.

RESULTS

Transcystic stenting was the 'intention-to-treat' basis of therapy for 56 of the patients. The placement of the stent only failed once when the stent became trapped in the cystic duct. Complications of the operation included: pain and jaundice (n = 2), cholangitis (n = 1), and pulmonary embolus (n = 1). The median postoperative hospitalization was 2 days (range: 1-15). Five further patients had common bile duct stones removed via a choledochotomy; a stent was placed through the choledochotomy before its closure. The selective common bile duct cannulation rate at the first endoscopic retrograde cholangio-pancreatography, was 98%. A second endoscopic retrograde cholangio-pancreatography was required in 15% of patients. The only complication of all the endoscopic procedures was a single case of mild cholangitis; there were no cases of pancreatitis.

CONCLUSION

A treatment option open to all surgeons for non-jaundiced patients with known choledocholithiasis or choledocholithiasis found at operative cholangiogram, is the transcystic stenting of the sphincter of Oddi at the time of laparoscopic cholecystectomy. At a subsequent sitting, the common bile duct can be safely cleared endoscopically using a sphincterotomy facilitated by the stent.

Endolaparoscopic rendezvous treatment: a satisfying therapeutic choice for cholecystocholedocolithiasis

BACKGROUND

There are many different strategies for the treatment of the main bile duct lithiasis. When lithiasis of the biliary tract is suspected at a preoperative stage, we can treat patients with sequential treatment: endoscopic netrograde cholangiopancreatography followed by laparoscopic cholecystectomy. If common bile duct-lithiasis is recognized at an intraoperative stage, many options for treatment exist, one of which is intraoperative retrograde endoscopic sphincterotomy (ES) (laparoendorendezvous).

METHODS

We report our experience using the aforementioned technique with 58 patients affected by cholelithiasis and complex Common bile duct disease who underwent laparoscopic cholecystectomy and intraoperative ES consecutively from March 1996 to May 2000. Of the 58 patients, 43 were affected by cholecystocholedocolithiasis: 12 by previously described lithiasis plus stenosant papillitis, 2 also by a pancreas head cancer, and 1 by cancer of the papilla.

RESULTS

The combined technique was performed in 86% of the cases. Six patients required conversion to open surgery. In two other patients, laparoscopic choledocotomy was performed with positioning of a Kehr-tube for an ampulla-impacted lithiasis.

CONCLUSIONS

Intraoperative ES offers a valid approach to the treatment of cholecystocholedocolithiasis in one session. Furthermore, it represents a valid alternative to transcholedocical laparoscopic treatment of cholelithiasis and complex common bite duct pathology.

Laparoscopic cholecystectomy in the new millennium

BACKGROUND

Laparoscopic cholecystectomy has become the gold standard for the treatment of symptomatic cholelithiasis. Many authors-including investigators at our institution, who reported one of the initial experiences with laparoscopic cholecystectomy in July 1992-have documented a definite learning curve associated with this procedure. We present a follow-up study of our experience with laparoscopic cholecystectomy and compare these data to an earlier study of the initial experience with laparoscopic cholecystectomy at the Beth Israel Medical Center.

METHODS

We retrospectively reviewed 300 consecutive patients from March 1998 through March 1999. The patient population was epidemiologically similar to that of the original study with regard to age, sex, and American Society of Anesthesia (ASA) classification. However, whereas the initial population included only patients with chronic disease, in our study 13.7% of the patients had been admitted through the emergency room with acute stone disease of the biliary tract.

RESULTS

We found a 5.7% conversion rate, a 1% rate of major complication, and a 5.7% rate of minor complication rates, as compared to the initial study's rates of 12%, 4%, and 10%, respectively. Whereas none of the patients in the original study left the hospital on the day of surgery and only 49% were discharged within 1 day, in our group, 29 patients (10%) underwent ambulatory procedures and an additional 186 patients (62%) were discharged on the 1st post-operative day. The average duration of the operation was 90 min, which did not represent a statistical improvement over the time of 93 min reported in the earlier study.

CONCLUSIONS

Since 1992, both the conversion rate and length of stay have declined at our hospital, but operative time has remained essentially the same. These findings probably reflect a bimodal learning curve, the increase in the number of cholangiograms and additional intraoperative procedures now performed, the greater severity of gallbladder disease currently treated with laparoscopic cholecystectomy, and increases in the number of attending physicians as well as the level of residents who perform this procedure.

Laparoscopic biliary surgery

Treatment of gallstones by laparoscopic cholecystectomy has become standard therapy over the past decade and has received wide patient acceptance. Problems are infrequent but those such as biliary injury may be serious and continue to be a cause of concern. Biliary injury is more likely when surgery is performed in the presence of acute inflammation. Laparoscopic bile duct exploration is becoming standardized and the results are good. The role of other laparoscopic biliary procedures such as biliary bypass is still uncertain.

Prospective evaluation of magnetic resonance cholangiography to detect common bile duct stones before laparoscopic cholecystectomy

BACKGROUND

With the advent of laparoscopic cholecystectomy, endoscopic retrograde cholangiography (ERC) is frequently employed before operation to detect common bile duct stones. However, this is an invasive technique with recognized complications. This study evaluated the accuracy of magnetic resonance cholangiography (MRC) to detect choledocholithiasis in selected patients before laparoscopic cholecystectomy.

METHODS

Patients scheduled for elective laparoscopic cholecystectomy, with risk factors for common bile duct stones, underwent MRC followed by ERC or peroperative cholangiography.

RESULTS

Over a 2-year period 40 patients were studied. MRC had a sensitivity of 88 per cent, specificity of 93 per cent, positive predictive value of 78 per cent and negative predictive value of 97 per cent for the detection of common bile duct stones.

CONCLUSION

MRC is a simple non-invasive method for preoperative screening for common bile duct stones in at-risk patients. In this study it would have reduced the need for ERC by three-quarters.