腹腔镜下胆总管切开取石术与经胆囊管取石术治疗胆总管结石伴胆囊结石患者疗效分析

目的 探讨胆总管结石伴胆囊结石患者治疗的最佳腹腔镜微创术式选择。 方法 2013年6月~2016年6月本院收治的胆总管结石伴胆囊结石患者500例,其中234例患者接受腹腔镜下胆总管切开取石（LCBDE）术,266例接受腹腔镜下经胆囊管取石术（LTSE）。在LCBDE组,采用腹腔镜胆囊切除术（LC）联合LCBDE和T管引流,在LTSE组,采用LC联合LTSE。比较两组治疗后结石清除率、手术时间、术后首次排气时间和住院时间、术后并发症和结石复发率。 结果 LCBDE组结石数量为（4.6±1.7）个,显著多于LTSE组的（3.1±2.4）个（P<0.05）,结石直径为（11.8±5.4） mm,显著大于LTSE组的（5.2±2.2） mm（P<0.05）,手术时间、首次肛门排气时间和住院时间分别为（114±27） min、（3.4±1.3）d和（7.1±3.2） d,显著长于LTSE组的（73±21） min、（2.2±0.9） d和（3.5±1.8）d（P<0.05）; LCBDE组结石清除率为94.9%,与LTSE组的94.7%比,差异无统计学意义（P>0.05）;LCBDE组并发症发生率为24.4%,显著高于LTSE组的10.9%（P<0.05）;在随访1年期间,LCBDE组结石复发率为4.7%,显著高于LTSE组的1.5%（P<0.05）。 结论 采用LC联合LTSE术治疗胆总管结石伴胆囊结石患者恢复较快,可明显缩短住院时间,且并发症发生率和远期结石复发率较低。     

左肝蒂阻断行左半肝微创手术治疗肝内胆管结石疗效研究

目的 探讨左肝蒂阻断行左半肝微创手术治疗肝内胆管结石患者的疗效。方法 2012年1月~2016年12月收治的肝内胆管结石患者73例,采用左肝蒂阻断行腔镜下左肝外叶切除术治疗40例,采用传统开腹手术行左肝外叶切除治疗33例,比较两组疗效情况。结果 腔镜组和开腹组手术时间分别为（274.0±57.4） min和 （216.0±33.8） min,术后疼痛缓解时间分别为（3.3±1.2） d和（5.2±1.5） d,术后排气时间分别为（22.9±7.5） h和（47.3±11.7） h,术后住院时间分别为（11.8±2.2）d和（16.3±3.1）d,差异均具有统计学意义（P<0.05）;两组患者手术出血量、并发症和住院总费用比较,差异无统计学意义（P>0.05）;治疗后,两组肝功能指标变化无显著相差（P>0.05）。结论 左肝蒂阻断行左半肝微创手术治疗肝内胆管结石患者与常规手术治疗比,具有安全可靠、创伤小、疼痛轻、恢复快、住院时间短等优点。     

经皮经肝胆道镜硬镜碎石术治疗肝内胆管结石患者临床疗效研究*

目的 探讨经皮经肝胆道镜（PTCL）硬镜碎石术治疗肝内胆管结石患者的临床疗效。方法 2013年3月~2015年3月我院诊治的肝内胆管结石患者200例,随机分为两组,每组100例,分别采取经皮经肝胆道镜硬镜手术取石治疗或常规开腹手术治疗。比较两组患者疗效和并发症发生率情况。结果 PTCL治疗组患者体质指数为（24.2±2.2） kg/m²,结石直径为（4.3±0.5） mm,结石位于左肝管、右肝管和左右肝管比例分别为56.0%、37.0%和7.0%,与开腹组【分别为（24.0±3.0） kg/m²、（4.4±0.6） mm、55.0%、39.0%和6.0%】比,差异均无统计学意义（P>0.05）;两组均顺利完成手术,取净结石;PTCL组手术时间为（154.3±21.8） min,术中出血量为（96.3±15.8） ml,肛门排气时间为（1.1±0.5） d,术后住院日为（7.7±0.9） d,均显著短于或少于开腹组【分别为（247.6±30.5） min、（190.0±10.5） ml、（1.9±0.4） d和（10.0±1.2） d,P<0.05】;术后,PTCL组发生切口感染、腹腔感染、肺部感染或胆汁漏等并发症3例（3.0%）,显著少于开腹组的11例（11.0%,x²=4.902,P<0.05）;术后2 w,PTCL组血清ALT和AST水平为（43.9±9.5） u/l和（40.3±8.9） u/l,与开腹组的（42.3±10.2） u/l和（43.4±10.5） u/l比,无显著性差异（P>0.05）,而血清TBIL水平为（18.9±3.2） μmol/l,显著低于开腹组的（23.0±3.1） μmol/l（P<0.05）;术后1年末,经B超复查,PTCL治疗患者结石复发2例（2.0%）,显著少于开腹组的9例（9.0%,x²=8.901,P<0.01）;术后2年末,经B超复查,PTCL治疗患者结石累计复发3例（3.0%）,显著低于开腹组的15例（15.0%,x²=11.071,P<0.01）。结论 采用经皮经肝胆道镜硬镜碎石术治疗肝内胆管结石患者能够加快患者康复进程,降低术后并发症的发生,在两年观察期间,结石复发率较低,值得临床进一步研究。     

经腹腔顺行放置鼻胆管引流联合胆总管一期缝合在胆总管结石治疗中的应用*

目的 探讨经腹腔顺行放置鼻胆管引流联合胆总管一期缝合在胆总管结石治疗中的应用价值。方法 2014年3月~2017年3月我科收治的164例胆囊结石合并胆总管结石患者,采用随机数字表法将患者分成观察组82例和对照组82例。两组均采用腹腔镜胆囊切除术,然后行胆总管探查。在观察组,行腹腔顺行放置鼻胆管引流联合胆总管一期缝合,在对照组行放置T管引流,观察两组患者术中出血量、手术时间、肠功能恢复时间等相关临床指标,比较两组患者胆汁漏、肠道出血、胰腺炎等并发症发生情况。结果 观察组患者术中出血量为（36.1±10.2）mL,与对照组[（32.2±13.2）mL,P>0.05]比,差异无统计学意义;手术时间为（96.6±21.5） min,与对照组[（91.5±19.1） min,P>0.05]比,差异也无统计学意义;肠功能恢复时间为（1.4±0.5） d,显著短于对照组[（2.3±0.5）d,P<0.05];引流管放置时间为（5.5±1.6） d,显著短于对照组[（90.8±2.3） d,P<0.05];住院时间为（7.4±1.4） d,显著短于对照组[（9.5±2.4）d,P<0.05],但住院费用为（38822.2±4019.7）元,显著高于对照组[（26744.5±3277.7）元,P<0.05];术后1 d,观察组患者胆汁引流量为（267.3±102.8）mL,与对照组[（266.5±112.6）mL,P>0.05]比,差异无统计学意义;术后2 d,胆汁引流量为（221.3±128.2）mL,显著少于对照组[（313.3±117.6）mL,P<0.05];术后3 d,胆汁引流量为（191.9±138.5）mL,显著少于对照组[（270.8±121.8） mL,P<0.05];两组引流失败、胆汁漏、肠道出血和胰腺炎等并发症发生率比较,无显著差异（8.4%对12.2%,P>0.05）。结论 采用腹腔顺行放置鼻胆管引流联合胆总管一期缝合治疗胆囊结石合并胆总管结石患者具有较好的临床应用价值,显著缩短了带管和住院时间,但需掌握好手术适应证。     

腹腔镜联合胆道镜手术治疗肝包虫病患者初步疗效研究

目的 探讨腹腔镜联合胆道镜手术治疗肝包虫病患者的临床效果。方法 2015年2月~2016年8月在我院接受手术治疗的104例肝包虫病患者,52例接受经腹腔镜下内囊摘除术,另外52例采用经腹腔镜联合胆道镜内囊摘除术治疗,比较两组患者的治疗效果。结果 腹腔镜联合胆道镜手术患者胆漏检出率为80.8%,明显高于腔镜组的63.5%（P<0.05）;术中出血量为（33.2±20.8）ml,明显少于腔镜组的【（82.1±45.3）ml,P<0.05】;胆漏发生率、感染发生率、拔管时间、肠腔排气时间、住院日分别为9.6%、13.5%、（11.5±4.6） d、（1.8±0.7）d、（10.5±5.3）d,明显优于腔镜组的【34.6%、36.5%、（24.3±7.8）d、（3.3±0.6）d、（17.1±7.8）d,P<0.05】。结论 腹腔镜联合胆道镜手术治疗肝包虫病患者,效果确切,不良反应少,与传统单纯应用腹腔镜手术比,具有疗效好、创伤小、恢复快等优点。     

手术治疗胆石症并发急性胰腺炎患者血清炎症和氧化应激介质的变化

目的 探讨胆石症并发急性胰腺炎（AP）患者在病情稳定后接受腹腔镜胆囊切除术（LC）治疗血清炎性和氧化应激介质的变化。 方法 150例胆石症并发AP患者,在内科治疗病情稳定后,84例接受LC术,66例接受开腹胆囊切除术。采用ELISA法检测血清白介素-6（IL-6）、IL-10和C反应蛋白（CRP）;采用ELISA法检测血清丙二醛（MDA）、氧化型低密度脂蛋白（ox-LDL）和对氧磷酶-1（PON-1）;采用高效液相色谱法检测血清8-羟基鸟嘌呤（8-OHG）。 结果 术后第5天,LC组血清IL-6水平为（42.3±4.8）μg/L,显著低于开腹组的【（57.7±5.1）μg/L,P<0.05】,IL-10水平为（64.3±5.3） pg/ml,显著高于开腹组的【（51.2±4.2） pg/ml,P<0.05】,CRP水平为（15.8±5.7）μg/L,显著低于开腹组的【（38.4±6.8） μg/L,P<0.05】;MDA水平为（3.3±0.9） nmol/mL,显著低于开腹组的【（5.4±1.8） nmol/mL,P<0.05】,ox-LDL水平为（63.2±11.7） ng/ml,显著低于开腹组的【（72.3±11.0） ng/ml,P<0.05】,PON-1水平为（116.3±10.2） U/ml,显著高于开腹组的【（104.5±11.4） U/ml,P<0.05】,8-OHG水平为（0.5±0.2）ng/ml,与开腹组的（0.6±0.2） ng/ml比,无显著性相差（P>0.05）。 结论 对于胆石症并发AP患者,在内科控制AP病情后,及时行LC手术治疗,去除结石,可以减轻患者的氧化应激反应,安全可行。     

两种手术方法处理腹腔镜胆囊切除术后胆总管残余结石患者临床疗效比较

目的 分析比较经内镜逆行性胰胆管造影（ERCP）下取石与开腹胆道探查（CBDE）治疗腹腔镜胆囊切除术（LC）后胆总管残余结石患者的临床疗效。方法 2015年2月~2016年12月我院收住的经LC术后存在胆总管残余结石患者84例,其中38例采取CBDE法（A组）治疗,46例采取ERCP下取石（B组）。结果 B组术中出血量明显少于A组[（3.4±1.3）ml对（124.2±65.8）ml,P<0.05],手术时间[（34.8±4.2）min对（123.3±15.8）min,P<0.05]、术后排气时间[（1.0±0.7）h对（42.6±9.1）h,P<0.05]和住院时间[（4.9±3.5）d对（9.3±4.3）d,P<0.05]均明显短于A组;术后1 w,B组血清GGT水平为（63.7±7.5）IU/L,与A组的（70.2±7.9）IU/L 比无显著性相差（P>0.05）,血清ALP水平为（105.6±11.5）IU/L,与A组的（115.4±12.8）IU/L比无显著性相差（P>0.05）;A组并发症发生率为23.7%、结石再复发率为5.3%,而B组分别为15.2%和6.5%,两组比较无显著性差异（P>0.05）。结论 相对于CBDE术,采用ERCP下取石处理经LC术后胆总管残余结石患者可有效降低术中出血量,缩短手术时间,并因可反复进行而具有优势。     

经皮经肝胆囊穿刺引流术联合延期胆囊切除术治疗急性胆囊炎患者近期疗效研究*

目的 观察经皮经肝胆囊穿刺引流术（PTGBD）联合延期腹腔镜胆囊切除术（LC）治疗急性胆囊炎患者的近期临床效果。方法 2015年8月~2017年8月我院收治的94例急性胆囊炎患者被分为两组,47例观察组患者采取PTGBD联合延期LC治疗,另47例对照组采取急诊LC治疗。结果 观察组 手术时间为（83.2±34.1） min,显著短于对照组【（119.0±36.4） min,P<0.05】,手术失血量为（33.7±15.5） ml,显著少于对照组【（60.4±16.7） ml,P<0.05】,术后肛门排气时间为（23.5±6.6） h,显著短于对照组【（27.2±5.1） h,P<0.05】,术后腹腔引流时间为（3.4±2.0） d,显著短于对照组【（9.1±3.1）d,P<0.05】,而总住院时间为（11.2±4.7） d,显著长于对照组【（8.3±3.0）d,P<0.05】;观察组腔镜中转开腹率和直接开腹率分别为4.3%和0.0%,显著低于对照组的17.0%和12.8%（P<0.05）;术后72 h,观察组白细胞计数、谷丙转氨酶、谷草转氨酶和总胆红素水平显著低于对照组（P<0.05）;观察组短期并发症发生率为8.5%,显著低于对照组的29.8%（P<0.05）。结论 采取PTGBD联合延期LC治疗急性胆囊炎患者临床疗效确切,可有效降低腔镜手术中转开腹率和术后并发症发生率,临床上应尽量避免急诊行LC手术。     

不同Calot三角解剖入路腹腔镜胆囊切除术治疗胆囊结石伴慢性胆囊炎患者疗效对比分析

目的 比较不同Calot三角解剖入路在腹腔镜胆囊切除术（LC）中的应用效果。方法 根据不同Calot三角解剖入路方式分组,在行LC术治疗胆囊结石伴慢性胆囊炎患者时,100例采用胆囊后三角解剖入路（观察组）,另100例采用胆囊三角入路（对照组）,采用免疫比浊法测定血清C反应蛋白（CRP）,采用ELISA法测定血清白细胞介素-6（IL-6）、白介素-8（IL-8）和肿瘤坏死因子-α（TNF-α）水平,采用视觉模拟评分（VAS）工具评估疼痛程度,比较两组手术指标及手术前后血清细胞因子水平变化。结果 在手术中,发现观察组胆囊周围出现粘连53例,对照组50例;两组无胆囊粘连患者组间各手术指标、手术并发症和中转开腹发生率比较均无显著性差异（P>0.05）;观察组粘连患者手术时间、术中出血量、术后肠功能恢复时间、住院时间和术后VAS评分分别为（29.4±4.3） min、（33.9±4.6） ml、（26.0±4.2） h、（6.0±1.0） d和（4.0±1.5） 分,均显著少于或轻于对照组粘连患者【（59.1±5.5） min、（45.6±4.1） ml、（30.3±4.5） h、（8.4±1.0） d和（4.8±1.3） 分,P<0.05】;观察组胆囊粘连患者无并发症和中转开腹者,而对照组胆囊粘连患者则分别为8.0%和8.0%（P<0.05）;治疗后,观察组血清CRP、IL-6、IL-8和TNF-α水平均显著低于对照组（P<0.05）。结论 经胆囊后三角解剖入路行LC术能明显减少胆囊粘连患者术中出血量,显著降低并发症和中转开腹发生率。在LC术中需密切观察胆囊粘连与否及其程度等情况,而给予合理的处理。     

围手术期应用乌司他丁治疗对肝细胞癌患者肝切除术后外周血Th22细胞百分比和血浆白细胞介素-22的影响*

目的 观察围手术期应用乌司他丁对肝细胞癌（HCC）肝切除手术患者术后外周血Th22细胞百分比和血浆白细胞介素（IL）-22水平的影响。方法 2015年7月~2017年4月解放军昆明总医院普通外科行肝切除手术的HCC患者88例,术后51例接受常规治疗,37例另加乌司他丁治疗7 d。另选30例健康人作为对照。分离外周血单个核细胞（PBMC）,使用流式细胞术检测CD3⁺CD4⁺IL-22⁺的Th22细胞百分比,采用ELISA法检测血浆IL-22水平。对符合正态分布的计量资料比较采用独立样本t检验,对于非正态分布的计量资料比较采用Mann-Whitney检验。结果 HCC患者外周血Th22细胞百分比为（1.4±0.3） %,显著高于健康人【（0.8±0.1） %,P<0.0001】;HCC患者血浆IL-22水平为（116.9±32.6） pg/ml,亦显著高于健康人【（42.1±18.2） pg/ml,P<0.0001】;在术后3 d,乌司他丁治疗组和常规治疗组血清ALT分别为【219.4（40.1,510.9） IU/L和450.6（56.1,820.7） IU/L,P<0.05】,血清AST分别为【108.8（82.5,439.1） IU/L和257.3（115.3,7265） IU/L,P<0.01】;在术后7 d,乌司他丁治疗组和常规治疗组血清ALT分别为【72.4（25.6,471.5） IU/L和115.4（35.7,625.2） IU/L,P<0.05】,血清AST分别为【61.4（29.4,351.4） IU/L和90.5（45.5,293.8） IU/L,P<0.05】;术后3 d和术后7 d,乌司他丁治疗组外周血Th22细胞百分比分别为（1.2±0.4）%和（1.1±0.3）%,较常规治疗组显著降低【分别为（1.3±0.3）%,P<0.05和（1.3±0.2） %,P<0.05】;血浆IL-22水平分别为（98.1±20.1） pg/ml和（94.1±24.8） pg/ml,亦较常规治疗组显著降低 【分别为（109.7±29.8） pg/ml,P<0.05和（110.7±37.1）%,P<0.05】。结论 肝切除术后应用乌司他丁治疗可降低外周血Th22细胞比例和血浆IL-22水平,对肝功能具有一定的保护作用     

Comprehensive review on small common bile duct stones

Common bile duct stones are among the most common conditions encountered by endoscopists. Therefore, it is well researched; however, some items, such as indications for endoscopic papillary balloon dilatation(EPBD), safety of EPBD and endoscopic sphincterotomy in patients receiving dual antiplatelet therapy or direct oral anticoagulant, selection strategy for retrieval balloons and baskets, lack adequate evidence. Therefore, the guidelines have been updated with new research, while others remain...     

处置困难胆总管结石1例治疗体会

采用常规取石技术仍未能取出的结石,被认为是处置"困难"的胆总管结石。现将我院收治的1例处置困难的胆总管结石患者治疗经过和治疗体会报道如下。     

Laparoscopic management of common bile duct stones

We reviewed our experience with the management of common bile duct (CBD) stones in 100 consecutive patients treated laparoscopicaly during the past 9 years (1990—1998) and evaluated the advantages, disadvantages, and feasibility of the treatment, to elucidate reasonable therapeutic strategies for patients harboring CBD stones. We conclude that the most rational management of CBD stones is that which is decided according to the size of the CBD, which, in turn, depends on the size, number, and location of stones. The cystic duct in patients with a non‐dilated CBD is narrow, because the size of the CBD depends on the size and number of stones that have migrated through the narrow cystic duct, and the stones in the non‐dilated CBD are therefore usually small in size and number. Patients with a dilated CBD, however, are good candidates to undergo single‐stage laparoscopic treatment. In our Department, therefore, even if complete removal of stones has failed in patients with non‐dilated CBD, further choledochotomy is not carried out, and a C‐tube is placed through the cystic duct for a subsequent postoperative transduodenal approach, because laparoscopic transcystic CBD exploration and choledochotomy may not be always feasible in those patients with non‐dilated CBD, and spontaneous migration of small stones into the duodenum is frequently noted. In fact, some stones demonstrated on intraoperative cholangiograms were not revealed by postoperative cholangiography. In contrast, retained stones detected postoperatively were successfully removed by postoperative endoscopic sphincterotomy (EST), the endoscopic papillary balloon dilatation technique (EPBDT), or postoperative cholangioscopy (POCS) without any injury to the sphinter of Oddi. With this approach, we believe that the causes of stone recurrence can be avoided in the majority of cases.     

Technical aspects in the laparoscopic management of complicated common bile duct stones

The management of common bile duct (CBD) stones traditionally required open laparotomy and bile duct exploration. With the advent of endoscopic and laparoscopic technology in the latter half of last century, endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) has become the mainstream treatment for CBD stones and gallstones in most medical centers around the world. However, in certain situations, ERCP cannot be feasible because of difficult cannulation and extraction. ERCP can also be associated with potential serious complications, in particular for complicated stones requiring repeated sessions and additional maneuvers. Since our first laparoscopic exploration of the CBD (LECBD) in 1995, we now adopt the routine practice of the laparoscopic approach in dealing with endoscopically irretrievable CBD stones. The aim of this article is to describe the technical details of this approach and to review the results from our series.     

Spontaneous passage of common bile duct stones in jaundiced patients

BACKGROUND:Common bile duct(CBD)stones are known to pass spontaneously in a significant number of patients. This study investigated the rate of spontaneous CBD stones passage in a series of patients presenting with jaundice due to gallstones.The patients were managed surgically,allowing CBD intervention to be avoided in the event of spontaneous passage of CBD stones. METHOD:Retrospective analysis of patients presenting with jaundice due to CBD stones,and managed surgically with laparoscopic cholecystectomy ...     

Predictors of common bile duct lithiasis in laparoscopic era

AIM:To analyze retrospectively the records of 294 conse-cutive patients operated upon for gallbladder stones, to determine the predictive factors of synchronous common bile duct (CBD) stones and validate prospectively the generated model. METHODS: The prognostic estimation of a biochemical test and ultrasonography alone to differentiate between the absence and presence of choledocholithiasis was assessed using receiver operating characteristics curve analysis. Multivariate analysis was employed using discriminant analysis for establishment of a best model.Prospective validation of the model was made. RESULTS: Discriminant forward stepwise analysis disclosed that high values (≥2×normal) of SGOT,ALP, conjugated bilirubin and CBD diameter on ultrasound ≥10 mm were all prognostic factors of CBD lithiasis in univariate and multivariate analysis, P<0.01. History was not included in the model.Prospective validation of the model was performed by multivariate analysis using Visual General Stepwise Regression. Positive predictive value, when considering all these predictors,was 93.3%,while the negative predictive value was 88.8%.Sensitivity of the model was 96.5% and specificity 80%. CONCLUSION: The above model can be objectively applied to predict the presence of CBD stones.     

Residual common bile duct stones on direct peroral cholangioscopy using ultraslim endoscope

AIM:To detect and manage residual common bile duct(CBD)stones using ultraslim endoscopic peroral cholangioscopy(POC)after a negative balloon-occluded cholangiography.METHODS:From March 2011 to December 2011,a cohort of 22 patients with CBD stones who underwent both endoscopic retrograde cholangiography(ERC)and direct POC were prospectively enrolled in this study.Those patients who were younger than 20 years of age,pregnant,critically ill,or unable to provide informed consent for direct POC,as well as those with concomitant gallbladder stones or CBD with diameters less than 10 mm were excluded.Direct POC using an ultraslim endoscope with an overtube balloon-assisted technique was carried out immediately after a negative balloon-occluded cholangiography was obtained.RESULTS:The ultraslim endoscope was able to be advanced to the hepatic hilum or the intrahepatic bile duct(IHD)in 8 patients(36.4%),to the extrahepatic bile duct where the hilum could be visualized in 10 patients(45.5%),and to the distal CBD where the hilum could not be visualized in 4 patients(18.2%).The procedure time of the diagnostic POC was 8.2 ± 2.9 min(range,5-18 min).Residual CBD stones were found in 5(22.7%)of the patients.There was one residual stone each in 3 of the patients,three in 1 patient,and more than five in 1 patient.The diameter of the residual stones ranged from 2-5 mm.In 2 of the patients,the residual stones were successfully extracted using either a retrieval balloon catheter(n = 1)or a basket catheter(n = 1)under direct endoscopic control.In the remaining 3 patients,the residual stones were removed using an irrigation and suction method under direct endoscopic visualization.There were no serious procedure-related complications,such as bleeding,pancreatitis,biliary tract infection,or perforation,in this study.CONCLUSION:Direct POC using an ultraslim endoscope appears to be a useful tool for both detecting and treating residual CBD stones after conventional ERC.     

Management of common bile duct stones: controversies and future perspectives

BACKGROUND: The advent of endoscopic and minimally invasive techniques for diagnosis and treatment has revolutionised the management of bile duct stones. Yet several controversies still surround the optimal means of investigation and treatment. DISCUSSION: Scoring systems that classify patients according to their risk of harbouring bile duct stones are likely to decrease the number of unnecessary preoperative endoscopic cholangiopancreatograms (ERCPs) at the expense of a higher rate of positive intra-operative diagnosis, unless magnetic resonance cholangiopancreatography (MRCP) is used to supplement the clinical information. The current treatment that is generally preferred for patients with a high probability of bile duct stones is ERCP followed by laparoscopic cholecystectomy (LC), but the routine use of ERCP in this context has certain limitations. An alternative approach is offered by carrying out the necessary cholangiogram during LC. Laparoscopic choledochotomy requires technical skill and costly equipment and should usually be followed by T-tube drainage of the duct. A recent survey in Spain has shown that most surgeons prefer ERCP plus LC, but one recent randomised controlled trial showed advantages for the single-stage laparoscopic treatment of bile duct stones in terms of a shorter hospital stay; success rates and complication rates were similar for the two procedures. The authors support the consensus statement that the choice of diagnostic and therapeutic strategy should depend on local circumstances and available expertise.     

Single-session minimally invasive management of common bile duct stones

Up to 18% of patients submitted to cholecystectomy had concomitant common bile duct stones. To avoid serious complications, these stones should be removed. There is no consensus about the ideal management strategy for such patients. Traditionally, open surgery was offered but with the advent of endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) minimally invasive approach had nearly replaced laparotomy because of its well-known advantages. Minimally invasive approach could be done in either two-session (preoperative ERCP followed by LC or LC followed by postoperative ERCP) or single-session (laparoscopic common bile duct exploration or LC with intraoperative ERCP). Most recent studies have found that both options are equivalent regarding safety and efficacy but the single-session approach is associated with shorter hospital stay, fewer procedures per patient, and less cost. Consequently, single-session option should be offered to patients with cholecysto-choledocholithiaisis provided that local resources and expertise do exist. However, the management strategy should be tailored according to many variables, such as available resources, experience, patient characteristics, clinical presentations, and surgical pathology.