The role of cholecystectomy following endoscopic sphincterotomy and bile duct stone removal

INTRODUCTION

Choledocholithiasis is common, with patients usually treated with endoscopic retrograde cholangiopancreatography (ERCP) and subsequent cholecystectomy to remove the presumed source of common bile duct (CBD) stones. However, previous investigations into the management of patients following ERCP have focused on recurrent CBD stones, negating the risks of cholecystectomy. This article appraises the role of cholecystectomy following successful endoscopic clearance of bile duct stones.

METHODS

Patients undergoing ERCP and CBD clearance for choledocholithiasis at St James's University Hospital January 2015-December 2018 were included. Patients were divided into those who received cholecystectomy and those managed non-operatively. Readmissions, operative morbidity, mortality and treatment costs were investigated.

RESULTS

Eight hundred and forty-four patients received ERCP and CBD clearance with 3.9 years follow-up. Two hundred and nine patients underwent cholecystectomy with 15% requiring complex surgery. Three hundred and seventy-three patients were non-operatively managed. Unplanned readmissions occurred in 15% following ERCP, mostly within two years. There was no difference in readmissions between the two groups. Accounting for the entire patient pathway, non-operative management was less expensive.

CONCLUSIONS

The majority of patients do not require readmission following ERCP for CBD stones, and cholecystectomy did not reduce the risk of readmission. Few patients have recurrent CBD stones, but complex biliary surgery is frequently required. Routine cholecystectomy following ERCP needs to be re-evaluated and a more stratified approach to future risk developed.

How should we secure the cystic duct during laparoscopic cholecystectomy? A UK-wide survey of clinical practice and systematic review of the literature with meta-analysis

INTRODUCTION

It is currently unknown which method of cystic duct closure is most effective at reducing the risk of bile leak after laparoscopic cholecystectomy. The aims of this work were to determine the most common closure methods used in the UK and review available evidence on which method has the lowest risk of bile leak.

METHODS

We conducted an online survey through the Association of Upper Gastrointestinal Surgeons (AUGIS). We also undertook a systematic review using PubMed, EMBASE, MEDLINE and the Cochrane Library for studies that compared different methods for cystic duct occlusion and reported postoperative bile leak.

FINDINGS

There was significant variation in practice between consultant surgeons. For routine laparoscopic cholecystectomy metal clips were used most (64%) followed by locking polymer clips (33%) and suture ties (3%). In cases of a dilated cystic duct, preferences were locking polymer clips (60%), suture ties (30%) and metal clips (5%). We included six studies in our review with a total of 8,011 patients. Metal clips were associated with an increased odds of bile leak compared with locking polymer clips (OR 5.66, 95% CI 1.13-28.41, p=0.04) or suture ties (OR 4.17, 95% CI 0.72-24.31, p=0.12). Most studies were retrospective, unlikely to be adequately powered, and vulnerable to selection bias.

CONCLUSIONS

Limited available evidence suggests that metal clips have the highest risk of bile leak, but results are not strong enough to recommend a change in current clinical practice. A trial is now required to determine the best method of cystic duct closure.

Defining core patient descriptors for perforated peptic ulcer research: international Delphi

BACKGROUND

Perforated peptic ulcer (PPU) remains a common condition globally with significant morbidity and mortality. Previous work has demonstrated variation in reporting of patient characteristics in PPU studies, making comparison of studies and outcomes difficult. The aim of this study was to standardize the reporting of patient characteristics, by creating a core descriptor set (CDS) of important descriptors that should be consistently reported in PPU research.

METHODS

Candidate descriptors were identified through systematic review and stakeholder proposals. An international Delphi exercise involving three survey rounds was undertaken to obtain consensus on key patient characteristics for future research. Participants rated items on a scale of 1-9 with respect to their importance. Items meeting a predetermined threshold (rated 7-9 by over 70 per cent of stakeholders) were included in the final set and ratified at a consensus meeting. Feedback was provided between rounds to allow refinement of ratings.

RESULTS

Some 116 clinicians were recruited from 29 countries. A total of 63 descriptors were longlisted from the literature, and 27 were proposed by stakeholders. After three survey rounds and a consensus meeting, 27 descriptors were included in the CDS. These covered demographic variables and co-morbidities, risk factors for PPU, presentation and pathway factors, need for organ support, biochemical parameters, prognostic tools, perforation details, and surgical history.

CONCLUSION

This study defines the core descriptive items for PPU research, which will allow more robust synthesis of studies.

P11: NEAR INFRARED FLUORESCENT CHOLANGIOGRAPHY IN LAPAROSCOPIC CHOLECYSTECTOMY: A SINGLE CENTRE FEASIBILITY STUDY. THE OPTIMUM DOSING REGIME, LIMITATIONS AND WHERE NEXT?

Introduction

This study explored near-infrared fluorescent cholangiography (NIRFC) with Indocyanine Green (ICG) during laparoscopic cholecystectomy (LC) surgery in a tertiary referral hepatobiliary unit. ICG binds to albumin and is excreted in bile. NIRFC utilises the fluorescent and excretory properties of ICG to provide dynamic extrahepatic bile duct mapping during LC.

Method

Non-randomised single centre feasibility study. Twenty-two participants were sequentially allocated to four dosing subgroups prior to NIRFC assisted LC. Each received a single intravenous dose of ICG prior to LC with the Stryker Novadaq NIR laparoscope. The biliary anatomy was assessed with NIRFC at three time-points, detection was compared to radiological cholangiogram where available and surgeon satisfaction was assessed.

Result

Eight participants received 2.5mg ICG 20-40min before surgery, four 0.25mg/kg 20-40min, five 90min – 180min and five 12 – 36 hour pre-operatively. Average age 50 years (S.D±15), BMI 27.5m2 (S.D±3.6), 6/22 were acute LC procedures. The prolonged dosing interval produced increased extrahepatic biliary structure identification (p = 0.016), reduced noise to signal ratio and was consistently preferred by the operating surgeon. NIRFC was inferior to radiological cholangiogram (n = 10) (p = 0.014) for bile duct mapping. We observed iatrogenic bile spillage saturating the field and obscuring structure differentiation and peri-hilar inflammation impeding fluorescent detection in acute LC.

Conclusion

The dosing regimen 0.25mg/kg ICG 12 to 36 hours prior to surgery provides optimum NIRFC structure visualisation. Fluorescent tissue penetrance is limited in acute peri-hilar inflammation. More research in to the efficiency of NIRFC in emergency LC is required.

Take-home message

An intravenous dose of 0.25mg/kg of Indocyanine Green 12 to 36 hours before surgery is the optimum dosing regimen for increased extra-hepatic bile duct structures with near infrared fluorescent cholangiography. The role of NIRFC in acute laparoscopic cholecystectomy surgery remains ill-defined.

Thrombotic complications following liver resection for colorectal metastases are preventable

BACKGROUND

Surgery for colorectal liver metastases (CRLM) can be expected to be associated with a significant rate of thromboembolic complications due to the performance of long-duration oncologic resections in patients aged 60 years.

AIMS

To determine the prevalence of clinically significant thrombotic complications, including deep venous thrombosis (DVT) and pulmonary embolus (PE), in a contemporary series of patients undergoing resection of CRLM with standard prophylaxis.

MATERIAL AND METHODS

A prospectively maintained database identified patients undergoing resection of CRLM from January 2000 to March 2007 and highlighted those developing thromboembolic complications. In addition, the radiology department database was reviewed to ensure that clinically suspicious thromboses had been confirmed radiologically by ultrasound in the case of DVT or computed tomography for PEs.

RESULTS

During the period of the study, 523 patients (336 M and 187 F) with a mean age of 65 years underwent resection. A major hepatectomy was performed in 59.9%. One or more complications were seen in 45.1% (n=236) of patients. Thrombotic complications were seen in 11 (2.1%) patients: DVT alone (n=4) and PE (n=7). Eight of 11 thrombotic complications occurred in patients undergoing major hepatectomy, 4 of which were trisectionectomies. Patients were anti-coagulated and there were no mortalities.

CONCLUSIONS

The symptomatic thromboembolic complication rate was lower in this cohort than may be expected in patients undergoing non-hepatic abdominal surgery. It is uncertain whether this is due entirely to effective prophylaxis or to a combination of treatment and a natural anti-coagulant state following hepatic resection.

A preventable cause of acute abdomen

Haemoperitoneum is an extremely rare presentation of hepatocellular carcinoma in the industrialised world. We present the first reported case in the UK. In contrast, up to 10% of hepatocellular carcinomas in Africa present in this way, the median time between presentation and death being just six weeks. Hepatitis B infection at birth and during childhood is the major cause of hepatocellular carcinoma in the developing world. The World Health Organisation, UNICEF and the World Bank have all advocated routine hepatitis B vaccination of children. This can reduce the burden of disease in these communities, among people in their productive years of life.