Management of Preoperatively Suspected Choledocholithiasis: A Decision Analysis

Background  The management of symptomatic or incidentally discovered common bile duct (CBD) stones is still controversial. Of patients undergoing elective cholecystectomy for symptomatic cholelithiasis, 5–15% will also harbor CBD stones, and those with symptoms suggestive of choledocholithiasis will have an even higher incidence. Options for treatment include preoperative endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy (ERCP/ES) followed by laparoscopic cholecystectomy, laparoscopic cholecystectomy with intraoperative cholangiogram (LC/IOC), followed by either laparoscopic common bile duct exploration (LCBDE) or placement of a common bile duct double-lumen catheter with postoperative management. The purpose of this analysis was to determine the optimal management of such patients. Methods  A decision analysis was performed to analyze the management of patients with suspected common bile duct stones. The basic choice was between preoperative ERCP/ES followed by LC, LC/IOC followed by LCBDE, or common duct double-lumen catheter (Fitzgibbons tube) placement with either expectant management or postoperative ERCP/ES. Data on morbidity and mortality was obtained from the literature. Sensitivity analysis was done varying the incidence of positive CBD stones on IOC with associated morbidity and mortality. Results  One-stage management of symptomatic CBD stones with LC/LCBDE is associated with less morbidity and mortality (7% and 0.19%) than two-stage management utilizing preoperative ERCP/ES (13.5% and 0.5%). Sensitivity analysis shows that there is an increase in morbidity and mortality for LC/LCBDE as the incidence of positive IOC increases but are still less than two-stage management even with a 100% positive IOC (9.4%, 0.5%). If a double-lumen catheter is to be used for positive IOC, the morbidity would be higher than two-stage management only if the positive IOC incidence is more than 65% but still with no mortality. Conclusion  LCBDE has lower morbidity and mortality rates compared to preoperative ERCP/ES in the management of patients with suspected CBD stones even if the chance of CBD stones reaches 100%. Using a common duct double-lumen catheter may be considered if LCBDE is not feasible and the chance of CBD stone is less than 65%. Presented in part at the 49th Annual Meeting of the Society for Surgery of the Alimentary Tract [Poster Session], San Diego, CA, May 17–21, 2008     

经T管窦道纤维胆道镜取石106例体会

目的 评估经T管窦道纤维胆道镜取出胆总管结石的临床价值。方法 肝外胆道结石术后带有T管引流的患者在拔掉T管之后，经T管窦道常规行纤维胆道镜检查，并取净残石。结果 106例病人一次取净结石103例，两次取净结石3例，无并发症发生。结论 术后经T管窦道取出胆总管残石的方法，安全，可靠，痛苦小。现已成为处理有T管窦道的胆总管残石的主要措施之一。     

腹腔镜胆管探查术Ⅰ期缝合与 T 管引流治疗胆总管结石的疗效比较

目的：比较腹腔镜胆总管探查取石术后 I 期缝合与 T 管引流治疗胆总管结石患者的临床治疗效果。方法：选取2015 年 5 月—2017 年 5 月就诊于我院成功进行腹腔镜手术治疗胆总管结石并获得完整随访资料的患者 77 例,并对其此两种不同术式的手术时间、术后胃肠功能恢复时间、术后住院时间、术后并发症、残余结石率进行比较分析。结果：I 期缝合组手术时间、术后胃肠道功能恢复时间及术后住院时间分别为（109.22±23.10） min、（10.65±3.32） h、（5.12±2.73） d,均显著低于 T 管引流组（125.28±28.38） min、（14.05±3.52） h、（11.23±3.18） d,差异具有统计学意义（P ＜ 0.05）,I期缝合组与 T 管引流组术后并发症发生率无显著差异,无统计学差异（P ＞ 0.05）。结论：腹腔镜胆管切开取石术后 I 期缝合胆管的治疗效果优于 T 管引流术,两者均具有临床安全有效性,在不同适应证前提下应根据患者的个体情况进行选择。     

腹腔镜胆总管探查内支架引流及T管引流治疗肝外胆管结石的临床研究

目的探讨腹腔镜胆囊切除胆总管探查（LCBDE）＋内支架引流或T管引流术治疗胆囊结石合并肝外胆管结石的疗效及临床价值。方法 回顾性分析湖北医药学院附属人民医院2008年6月至2013年6月期间由同一术者实施LCBDE的68例胆囊结石合并肝外胆管结石患者的临床资料。68例中行LCBDE＋内支架引流（支架引流组）22例,LCBDE＋T管引流术（T管引流组）46例。结果2组均顺利完成手术。支架引流组在肛门排气时间、腹腔引流时间、术后住院时间及住院费用方面均短于或少于T管引流组（P〈0．05）,而手术时间、术后胆红素水平及术后并发症发生率2组间的差异均无统计学意义（P〉0．05）。结论行LCBDE＋内支架引流和T管引流术各有其适应证。对适宜患者,LCBDE＋内支架引流术治疗肝外胆管结石患者的疗效优于LCBDE＋T管引流术。     

100 consecutive common duct explorations without mortality.

It has been suggested that the incidence of morbidity and mortality after common duct exploration no longer justifies its use in patients with a gallbladder in situ. Therefore endoscopic sphincterotomy has been advocated for removal of common duct stones before cholecystectomy in selected patients. The purpose of this study was to determine our current rate of retained common duct stones and the morbidity and mortality rates associated with common duct exploration. Charts of 100 consecutive patients who underwent cholecystectomy and common duct exploration from January 1982 through December 1986 were reviewed. Indications for duct exploration included jaundice, dilated common bile duct, gallstone pancreatitis, multiple small stones, and abnormal intraoperative cholangiogram. Common duct exploration was done by manual technique or choledochoscopy, as determined by the surgeon's preference. Only two patients required duodenotomy for extraction of difficult stones. There were no deaths in this series of consecutive common duct exploration. The total morbidity rate was 15.7%, which included a 5.3% incidence of retained common duct stones. There was a 7.4% major complication rate, including deep vein thrombosis, bleeding gastric ulcer, and pneumonia. The remaining complications were minor and did not prolong hospitalization. There was one wound infection and no postoperative pancreatitis. None of the complications were directly attributable to choledochotomy or duct exploration. All retained common duct stones were removed by endoscopic retrograde cholangiopancreatography or by angiographic basket and did not require reoperation. It is concluded that operative common duct exploration not requiring duodenotomy is safe and does not appreciably increase the incidence of complications after cholecystectomy. Endoscopic sphincterotomy continues to be the preferable alternative to operative common duct exploration for patients with retained common duct stones.     

Non-operative removal of retained stones in the common bile duct

A method of removal of retained common bile duct stones under radiological control is described and its use in 16 patients reported. The ease of the method, the minimal associated morbidity and the inexpensiveness of the equipment suggest that this should be the primary method of removal of retained stones when a T tube has been placed into the common bile duct.     

腹腔镜联合胆道镜胆总管探查取石术探讨

目的 探讨腹腔镜联合胆道镜胴总管探查治疗胆总管结石的手术方法及临床应用价值.方法 回顾性总结2006-2009年42例腹腔镜胆总管探查术的临床资料. 结果按照手术适应证,合理选择探查途径,改进胆总管切开缝合技术和胆总管取石技术.采用胆总管逐步电凝切开,分步缝合,纤维胆道镜鳄嘴钳逐步咬碎和吸引器套软管冲洗等方法.42例手术均获成功,无中转开腹,无术后出血和手术死亡.手术时间(120±30)min,手术失血(30±10)ml.41例取出胆总管结石,结石最多16枚,结石直径＞15 mm 18例,最大直径30 mm,术后轻度胆漏1例,结石残留3例,其中1例合并有肝内结石.42例中38例胆总管探查,35例T管引流,3例Ⅰ期缝合,4例经胆囊管探查,其中3例Ⅰ期胆囊管结扎,1例置管引流.42例均无胆道感染和胆道狭窄发生.结论 腹腔镜联合胆道镜胴总管探查治疗胆总管结石手术安全有效.通过合理选择探查途径,明显提高临床疗效.     

腹腔镜下胆总管一期缝合手术的临床研究和经验总结

目的研究腹腔镜胆总管一期缝合术治疗胆总管结石患者的临床治疗效果和经验总结。方法回顾性分析2013年~2017年在我院施行腹腔镜胆总管一期缝合术的患者41例(一期缝合组)的临床资料及手术资料,同时回顾性分析同期在我院行腹腔镜胆总管切开取石,T管引流术的患者43例(T管引流组)的临床资料及手术资料。结果一期缝合组在住院天数,排气时间少于T管引流组,其差异有统计学意义(P0.05),两组在手术时间,出血量,胆漏率,伤口感染率,胆道狭窄率等方面差异无统计学意义(P0.05)。一期缝合组和T管引流组分别有1例和2例胆瘘发生,均经过保守治疗痊愈。结论在严格把握适应症的基础上,腹腔镜胆总管一期缝合术治疗胆总管结石患者是安全有效的,但应该由有经验的医生操作。     

Retained common bile duct calculi.

A method of elimination of gallstones remaining in the common bile duct after exploration of the duct is described. The retained stone is flushed through the common duct sphincter into the duodenum using rapid infusion of normal saline via a T tube. The method is quick and simple and is recommended as the first step to take in the management of this discomforting group of patients. The method is not without potential morbidity and should only be carried out under carefully controlled conditions.     

腹腔镜胆道探查前瞻性非随机对照研究

目的:探讨腹腔镜胆道手术后不放置T管(胆道)引流的可行性。方法:对2005年2月至2005年11月我院治疗的行腹腔镜胆总管探查的25例患者进行了前瞻性非随机对照研究。分为两组,观察组未放置T管,共15例;对照组放置T管,共10例。结果:患者均恢复良好。随访1~5月,观察组未发现结石复发或其它并发症,对照组1例残余结石,1例胆道下端狭窄,均经保守治疗后痊愈出院。两组结石残留率、近期并发症发生率、住院费用等方面差异无显著性(P>0.05),而在手术时间、住院时间等方面差异有显著性(P<0.05)。结论:腹腔镜胆道探查是较成熟的治疗胆总管结石的方法,根据术前影像学检查及术中胆道镜检查结果,决定是否放置T管引流。     

腹腔镜联合胆道镜治疗继发性胆道结石术后并发症分析

目的 分析腹腔镜联合胆道镜治疗继发胆道结石的术后并发症。方法 105例患者依据检查结果采用2种不同的胆道探查方式：(1)胆囊结石合并胆道继发结石,胆囊管有明显扩张或经胆囊管扩张术可顺利通过胆道镜的患者,采用腹腔镜联合胆道镜经胆囊管胆道探查取石术(laparoscopic transcyctic common bile duct exploration,LTCBDE),术后不放“T”管引流;(2)若胆囊管细且无扩张,或胆囊管存在变异,采用腹腔镜联合胆道镜胆总管切开胆道取石术( laparoscopic common bile duct exploration,LCBDE)。其中若胆道内结石较少,结石无嵌顿则一期缝合胆道且不放“T”管,术后放腹腔引流管。若胆道下端结石嵌顿取石过程困难,或结石多、取石时间长则放“T”管引流同时放腹腔引流管。结果 共行LTCBDE+腹腔镜胆囊切除70例,LCBDE+腹腔镜胆囊切除35例,其中放T管14例,不放T管21例。术后腹腔积液17例,其中LTCBDE组6例,LCBDE组11例。胆汁性腹膜炎5例,LTCBDE组1例,LCBDE组4例。腹部疼痛13例,LTCBDE组4例,LCBDE组9例。体温增高11例,LTCBDE组3例,LCBDE组8例。以上并发症均经腹腔穿刺引流保守治疗痊愈。LCBDE组术后T管脱出2例,分别发生在术后当天和术后第2天,经再手术治愈。LCBDE组胆道残余结石14例,均经胆道镜完全取出;LTCBDE组随访43例,术后3个月复查B超未发现残余胆道结石。LTCBDE组中1例出现胆囊动脉夹脱落出血再次腹腔镜止血痊愈;LCBDE组术后放T管中有1例出现胆漏经腹腔引流10 d治愈。所有病例术后无胰腺炎发作。结论腹腔镜联合胆道镜治疗继发胆道结石可通过术前确切评估和术中正确处理避免或减少术后并发症的发生。     

Is surgical bile duct revision in choledocholithiasis still indicated?]

Endoscopic papillotomy with stone extraction is increasingly performed for the management of common bile duct stones either before cholecystectomy or as a sole procedure leaving the gallbladder in situ. We have therefore evaluated the method of operative common duct exploration. 94 cases with bile duct stones treated by cholecystectomy and common bile duct exploration were reviewed. The 30-day mortality was 2.1% with an overall morbidity of 19%. A retained stone was found on postoperative T-tube cholangiography in 6 patients and in all cases was removed percutaneously via the T-tube track. Patients were divided into three age groups (less than or equal to 60, 61-75, greater than 75 years). In each patient various risk factors were recorded. Correlation was made between age, risk factors and patient's morbidity. No correlation was found between age and morbidity. Patients with up to two risk factors had a morbidity of 10%. With three to four risk factors the morbidity increased to 19%, reaching 47% in patients with five and more risk factors. Cholecystectomy with common bile duct exploration is a safe procedure even in the elderly patient. Careful evaluation of risk factors is necessary. Endoscopic papillotomy with or without cholecystectomy should be considered in high risk patients.     

Complications of biliary T-tubes after choledochotomy

Background : Traditional management of choledocholithiasis has been supraduodenal choledochotomy, duct exploration and insertion of a T‐tube. This study reviews the complications associated with T‐tube use and assesses whether laparoscopic procedures are associated with an increase in complications relating to T‐tube use. Methods : Case records from two large public hospitals in New South Wales (Australia) were analysed retrospectively for a 10‐year period using a standardized data collection form. Morbidity, mortality and potential factors influencing the complication rate after choledochotomy and T‐tube insertion were recorded. All complications were reviewed by an experienced biliary surgeon. Results : T‐tubes were inserted in 274 patients, with 42 patients (15.3%) experiencing a total of 60 complications relating to T‐tube use. Morbidity occurring while the tube was in situ included fluid and electrolyte disturbance (five patients), sepsis (10 patients), premature dislodgement (three patients) and bile leakage (six patients). Complications resulting after planned tube removal included localized pain (13 patients), biliary peritonitis (seven patients), a prolonged biliary fistula (seven patients) and a late bile duct stricture (one patient). T‐tube complications resulted in a prolonged hospital stay (19 days vs 13 days, P = 0.005), 10 additional abdominal operations and two deaths. Complications related to T‐tubes were constant over the study period and were similar between laparoscopic and open cases (13.8%vs 15.5%, P = 0.81). Conclusions : Although this retrospective review is likely to have underestimated the incidence of T‐tube complications, it has demonstrated significant morbidity associated with T‐tube use. The incidence of these complications has been constant and is unrelated to a laparoscopic approach.     

Technique and results of biliary reconstruction using side-to-side choledochocholedochostomy in 300 orthotopic liver transplants.

OBJECTIVE: The authors evaluated the complication rate and outcome of side-to-side common bile duct anastomosis after human orthotopic liver transplantation. SUMMARY BACKGROUND DATA: Early and late biliary tract complications after orthotopic liver transplantation remain a serious problem, leading to increased morbidity and mortality. Commonly performed techniques are the end-to-end choledochocholedochostomy and the choledochojejunostomy. Both techniques are known to coincide with a high incidence of leakage and stenosis of the bile duct anastomosis. The side-to-side bile duct anastomosis has been shown experimentally to be superior to the end-to-end anastomosis. The authors present the results of 316 human liver transplants, in which a side-to-side choledochocholedochostomy was performed. METHODS: Biliary tract complications of 370 transplants in 340 patients were evaluated. Three hundred patients received primary liver transplants with side-to-side anastomosis of donor and recipient common bile duct. Thirty-two patients with biliary tract pathology received a bilioenteric anastomosis, and in eight patients, side-to-side anastomosis was not performed for various reasons. Clinical and laboratory investigations were carried out at prospectively fixed time points. X-ray cholangiography was performed routinely in all patients on postoperative days (PODs) 5 and 42. In patients with suspected papillary stenosis, endoscopic retrograde cholangioscopy and papillotomy were performed. RESULTS: One biliary leakage (0.3%) was observed within the early postoperative period (PODs 0 through 30) after liver transplantation. No stenosis of the common bile duct anastomosis was observed during this time. Late biliary stenosis occurred in two patients (0.6%). T tube-related complications were observed in 4 of 300 primary transplants (1.3%). Complications unrelated to the surgical technique, including papillary stenosis (5.7%) and ischemic-type biliary lesion (3.0%), which must be considered more serious in nature than complications of the anastomosis or T tube-related complications, were observed. Papillary stenosis led to frequent endoscopic interventions and retransplantations in 1.3%. CONCLUSIONS: Side-to-side common bile duct anastomosis represents a safe technique of bile duct reconstruction and leads to a low technical complication rate after human orthotopic liver transplantation. Ischemic-type biliary lesion evoked by preservation injury, arterial ischemia, cholestasis, and cholangitis may represent a new entity of biliary complication, which markedly increases the morbidity after human liver transplantation. Therefore, this complication should be the subject of further research.     

Early surgery for biliary pancreatitis

Herein, we documented our successful experience in performing definitive biliary tract surgery on patients with biliary pancreatitis as soon as the diagnosis was made and within 48 hours of admission. Early surgery reduced the length of hospital stay and did not result in associated morbidity, death, or complications of acute pancreatitis. The results of the study support the concept that removing obstruction of the pancreatic duct prevents progression of edematous pancreatitis to hemorrhagic pancreatitis. We conclude that patients with acute pancreatitis should be evaluated urgently for the presence of biliary tract stone disease and should be operated on as soon as the diagnosis of biliary pancreatitis is made, that early definitive surgery can be performed safely on patients with biliary pancreatitis, that cholecystectomy with intraoperative cholangiography and common duct exploration as necessary should be performed in all patients, and that length of stay for patients with biliary pancreatitis is reduced and morbidity and mortality possibly may be reduced by early surgery as compared with delayed surgery.     

A prospective randomised trial of bile duct reconstruction at liver transplantation: T tube or no T tube?

A prospective randomised study of end-to-end bile duct reconstruction with or without T-tube drainage during orthotopic liver transplantation (OLT) was undertaken in 60 patients well matched for age, sex, aetiology of liver disease, operative blood loss, cold ischaemic time, preoperative serum bilirubin level and Child-Pugh score. Significant biliary complications in the T tube group occurred in five patients and included bile duct stricture (n=2), bile leak/peritonitis (n=1) and cholangitis (n=2). Bile duct strictures occurred in six patients in the no T tube group (P>0.05, NS). Hepatic artery stenosis was identified in one patient from each group in association with a biliary stricture. Biliary complications in both groups were associated with a prolonged graft cold ischaemic time (P<0.01). As no significant difference was noted in the number of early and late biliary complications between the two groups, the routine use of a T tube has been discontinued.     

双镜联合治疗胆总管结石胆总管一期缝合的临床研究

目的探讨腹腔镜联合胆道镜治疗胆总管结石胆总管一期缝合临床应用价值。 方法回顾性分析2015年7月至2017年10月84例胆总管结石患者的病历资料，按手术方式的不同分为A组(27例，行腹腔镜联合胆道镜胆囊切除＋胆总管切开取石＋胆总管一期缝合术)、B组(29例，行腹腔镜联合胆道镜胆囊切除＋胆总管切开取石＋T管引流术)和C组(28例，传统的开腹胆囊切除＋胆总管切开取石＋T管引流术)。应用SPSS 22.0统计软件分析数据，一般资料和手术相关指标等计量资料以均数±标准差表示，采用F检验；手术后并发症等采用χ²检验。P<0.05为差异有统计学意义。 结果A组的出血量及术后住院时间均明显低于B组和C组，A组胃肠功能恢复时间明显低于C组，差异均有统计学意义(P<0.05)。各组手术后并发症总发生率比较，差异无统计学意义(P>0.05)。 结论在把握胆总管一期缝合的手术指征及具备熟练的腹腔镜、胆道镜操作技能下，对于胆囊结石合并胆总管结石患者，腹腔镜联合胆道镜双镜联合下行胆囊切除＋胆总管切开取石＋胆总管一期缝合术是安全可行的。     

胆囊结石合并胆管结石微创治疗方案的选择

目的探讨胆囊结石合并继发胆道结石微创治疗的合理方案。方法108例胆囊结石合并可疑胆道继发结石均行腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC），其中腹腔镜联合胆道镜经胆囊管胆道探查取石（laparoscopic transcyctic common bile duct exploration，LTCBDE）＋LC70例，腹腔镜联合胆道镜胆总管切开胆道取石（laparoscopic common bile duct exploration，LCBDE）＋LC35例，其中放T管14例，不放T管21例，内镜乳头肌切开术（endoscopic sphincterotomy，EST）术后行胆囊切除3例。结果LCBDE＋LC术后放T管组中有1例胆漏经保守治疗治愈，4例术后胆道造影发现胆道残余结石经胆道镜取出结石治愈．其他病例无胆漏，术后3月复查B超无残余胆道结石，所有病例术后无胰腺炎发作。结论在胆囊结石继发胆道结石的治疗中合理选择多种微创手术方法能降低创伤及减少并发症的发生。     

腹腔镜胆总管探查术诊治胆总管结石100例报告

目的：总结腹腔镜胆总管探查术诊治胆总管结石的经验教训,进一步探讨手术技巧及胆总管一期缝合的可行性。方法：回顾分析100例腹腔镜胆总管结石手术的临床资料,根据患者胆总管结石数量、大小,采用经胆囊管探查、经胆囊管胆总管交界处切开探查、直接胆总管切开探查三种处理方式。结果：经胆囊管探查7例,经胆囊管胆总管交界处切开探查25例,胆总管切开探查68例,其中放置T管7例,93例行胆总管一期吻合。术后发生胆漏5例,1例保守治疗,3例再次手术T管引流,1例行ERCP治疗。T管无法夹管1例,ERCP发现十二指肠乳头癌行胰十二指肠切除术。术后随访3个月-9年,随访率68％,胆总管结石复发4例,其中2例行EST治疗好转,2例保守治疗。结论：胆总管结石行腹腔镜手术应采取个体化的治疗方式,初期开展容易发生严重并发症,应严格把握手术准入制度,适当延长培训时间,以增加手术安全性。     

A modern analysis of morbidity after pancreatic resection

Complications after pancreatic resection remain prevalent. Procedure-related morbidity has previously focused on prevention of pancreatic and biliary fistulas (PFs and BFs) with other complications receiving less attention. We examined morbidity and its impact on reoperation, length of stay (LOS), and mortality following pancreatic resection. We retrospectively reviewed patients having elective pancreatectomy at the University of Tennessee affiliated hospitals during a recent 5-year time period. Factors examined included morbidity, mortality, and the need for reoperation. Patient deaths were analyzed with a focus on antecedent complications. Comparisons were made using Student's t test and chi2 analysis where appropriated. From 1997 to 2003, 125 patients had pancreatic resections: 93 Whipple procedures, 27 distal, and 5 total pancreatectomies. Twenty-nine patients (23%) did not have intraperitoneal drainage (IPD). Resections were performed for cancer in 75 per cent. Seventy complications occurred in 55 patients (44%). Morbidity related to an intra-abdominal process resulted in 16 reoperations and 4/6 deaths in this series (overall mortality, 4.8%). There were no BFs. Of 10 patients with PFs (8%), none required reoperation, and there was no PF-related mortality. No patient without IPD developed a PF. The presence of a PF significantly increased LOS when compared to those without (30.9 +/- 13.1 vs 17.4 +/- 12.2 days, P < 0.01). Forty-four per cent of all complications were related to either intra-abdominal abscess (IAA), hemorrhage, or feeding tube placement (18, 8, and 5, respectively). Management of IAA included percutaneous drainage in 16 and reoperation in 2 with 1 associated death. Hemorrhage necessitated reoperation in 6, resulted in 1 patient death, and was followed by IAA in 2. Of 5 jejunostomy tube complications, 4 required reoperation and 2 patients died. LOS was significantly greater in these 28 patients when compared to all others (28.1 +/- 16.9 vs 15.8 +/- 9.9 days, P < 0.001). Following pancreatectomy, 1) BFs should be a rare event; 2) PFs remain important but are most often managed nonoperatively with few sequelae; 3) in this series, IAA and hemorrhage were more common than PF, frequently mandated reoperation, prolonged hospitalization, and were associated with procedure related mortality; 4) feeding tube complications, though rare, are often catastrophic; 5) future efforts should focus on factors that could reduce abscess formation and a reduction in overall complications--many of which are potentially preventable.