Comparison of laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for choledocholithiasis: a prospective randomized study

Background

Endoscopic retrograde cholangiopancreatography and laparoscopic common bile duct exploration are safe and efficient methods that have recently been used for the treatment of bile duct stones. The aim of this study was to compare the efficacy, safety, and surgical outcomes of the laparoscopic common bile duct exploration plus laparoscopic cholecystectomy (LCBDE+LC) and endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy (ERCP+LC).

Methods

One hundred twenty patients were prospectively randomized into 2 groups: LCBDE with LC in a single intervention and LC after ERCP.

Results

The success rate of the LCBDE+LC group (96.5%) was found to be higher than for the ERCP+LC group (94.4%). Complication rates of the LCBDE+LC and ERCP+LC group were 7% and 11.1%, respectively. Complications requiring ERCP in the postoperative period after LCBDE+LC have been noted in 3.5% of cases.

Conclusions

Laparoscopic CBD exploration provides an alternative therapeutic approach that has less morbidity, is cost-effective, and allows earlier recovery with a reduced period of short-term disability.     

Sensitivity of endoscopic retrograde cholangiopancreatography standard cytology: 10-y review of the literature

Background

Biliary strictures present a unique diagnostic challenge to clinicians as they can be caused by both benign and malignant conditions. With the high mortalities associated with hepatopancreaticobiliary malignancies, accurate and rapid tissue diagnosis is imperative and typically done before initiation of treatment. However, the exact sensitivity of standard cytology from endoscopic retrograde cholangiopancreatography (ERCP) to diagnose malignancy remains unclear because of wide distribution of reported values in the literature. Furthermore, the use of radical surgery to obtain tissue when cytology is indeterminate has led to questions about the role of ERCP in patients with biliary strictures.

Methods

A PubMed search was conducted using the terms ERCP, cytology, and brushings. Articles reviewed were published between 2002 and 2012, had patient population with biliary stricture, and had ERCP brushing results and final pathology available for review. The cytology and pathology data were abstracted from each study, and the combined overall sensitivity was calculated.

Results

Sixteen studies were identified, with sensitivities ranging from 6%–64% and 99% confidence intervals (CIs) ranging from ±6% to ±32%. A combined total of 1556 patients were included, with positive ERCP cytology results in 358 cases. On final pathology, however, 861 patients were positive for malignancy. When the data were combined, we found an overall sensitivity of 41.6% ± 3.2% (99% CI) with a negative predictive value of 58.0% ± 3.2% (99% CI).

Conclusions

ERCP brushings suffer from low sensitivity and negative predictive value. This study questions the utility of ERCP to change the surgical management of these diseases in patients with radiographic evidence of a neoplasm or high suspicion of a malignancy.     

Impact of technical modification of endoscopic papillectomy for ampullary neoplasm on the occurrence of complications

Aim: To evaluate the usefulness of a modified technique of endoscopic papillectomy (EP) for lessening the occurrence of complications. Methods: Indications for EP were adenoma or well‐differentiated adenocarcinoma confined to the papilla of Vater (T1) without tumor spread into the bile/pancreatic duct. Sixteen patients underwent the modified technique, which consists of resection with the Endocut^® mode, followed by biliary/pancreatic sphincterotomy and stenting (Group A). Twelve patients who had undergone EP, using a cutting current, followed by pancreatic duct stenting were included as control (Group B). The frequency of complications and clinical outcomes were retrospectively compared between the two groups. Results: Sixteen patients had adenoma, and 12 had adenocarcinoma. Early complications occurred in 36% of all patients (hemorrhage, 7; cholangitis, 3; perforation, 2; cholecystitis, 1). The frequency of early complications in Group A was significantly lower than that in Group B (6% vs 75%, odds ratio [OR] 0.022, 95% confidence interval [CI], 0.0020–0.25). Late complications occurred in 18% of the patients (bile duct stone, 3; hemorrhage, 1; pancreatitis, 1). There was no significant difference in the late complication rate between Group A and Group B (19% vs 17%). Local recurrences were found in 14% of the patients, without a significant difference between Group A and Group B (19% vs 8%) during a mean follow‐up period. All recurrent tumors were successfully treated with argon plasma coagulation. Conclusions: The modified technique of EP for ampullary neoplasm contributed to lessening the occurrence of early complications. However, further refinement of this technique is necessary for improving the clinical outcome.     

Meta-analysis of one- vs. two-stage laparoscopic/endoscopic management of common bile duct stones

Background

The present study is a meta-analysis of English articles comparing one-stage [laparoscopic common bile duct exploration or intra-operative endoscopic retrograde cholangiopancreatography (ERCP)] vs. two-stage (laparoscopic cholecystectomy preceded or followed by ERCP) management of common bile duct stones.

Methods

MEDLINE/PubMed and Science Citation Index databases (1990–2011) were searched for randomized, controlled trials that met the inclusion criteria for data extraction. Outcomes were calculated as odds ratios (ORs) with 95% confidence intervals (CIs) using RevMan 5.1.

Results

Nine trials with 933 patients were studied. No significant differences was observed between the two groups with regard to bile duct clearance (OR, 0.89; 95% CI, 0.65–1.21), mortality (OR, 1.2; 95% CI, 0.32–4.52), total morbidity (OR, 0.75; 95% CI, 0.53–1.06), major morbidity (OR, 0.95; 95% CI, 0.60–1.52) and the need for additional procedures (OR, 1.58; 95% CI, 0.76–3.30).

Conclusions

Outcomes after one-stage laparoscopic/endoscopic management of bile duct stones are no different to the outcomes after two-stage management.     

快速康复外科在胆道结石患者ERCP术后饮食管理中的应用

目的探讨快速康复外科理念用于胆管结石患者ERCP术后饮食管理的效果。方法选择60例拟行ERCP取石的胆管结石患者,随机分为观察组与对照组各30例,两组患者术后当天均常规禁食。观察组患者术后次日如腹痛的症状及体征均不明显,且血淀粉酶正常或基本正常,则开始进食。对照组患者术后次日如腹痛的症状及体征均不明显,且血淀粉酶完全正常,则开始进食,否则延长观察期,继续禁食,直至结果正常后再逐步过渡到流质饮食及普食。比较两组患者术后口渴、饥饿感、输液量、住院时间的差异。结果观察组患者术后口渴、饥饿感发生率低于对照组;术后输液量、住院时间少于对照组。差异均有统计学意义(P<0.05)。均未发生出血、穿孔、胰腺炎的并发症。结论在胆管结石患者ERCP术后应用快速康复外科理念是安全、有效的,缩短了术后禁食时间,加快了病人康复速度,缩短了住院时间。     

ERCP治疗急性胆源性胰腺炎疗效的临床研究

目的回顾性分析ERCP术与传统开腹下胆总管切开取石术治疗胆源性胰腺炎的临床疗效。方法调取2012年1月至2015年10月安徽医科大学第一附属医院急诊外科收治的胆管结石伴急性胰腺炎患者病例86例,按照治疗方式不同分为ERCP组(56例应用ERCP+EST+ENBD)和CBDE组(传统开腹下胆总管切开取石+术中胆道镜探查+T管引流术30例)。观察两组术前及术后白细胞(WBC)、血淀粉酶(AMYL)、总胆红素(TBIL)、谷丙转氨酶(ALT)、CRP水平的变化及腹部症状缓解时间、肠道恢复时间、住院总时间、住院总费用、结石清除率及术后并发症。结果两组术前一般资料、各实验室指标及结石大小差异均无统计学意义(P0.05);ERCP组住院总时间、住院总费用、术后腹痛缓解及胃肠道通气时间均较CBDE组降低,差异有统计学意义(P0.05);且ERCP组术后第3天及第7天同一时间点WBC、AMYL、TBIL、ALT、CRP均较CBDE组降低,有统计学差异(P0.05)。结论 ERCP在胆总管结石伴急性胰腺炎的治疗中安全有效,术后恢复良好,可有效减少住院时间,降低住院总费用,减轻患者身体及经济负担。     

ERCP在十二指肠乳头癌诊断及治疗中的价值

目的 观察ERCP在十二指肠乳头癌诊断及治疗中的价值。方法 对14例十二指肠乳头癌病人的内镜表现、病理分型及行支架治疗效果进行统计分析。结果 14例经内镜诊断的十二指肠乳头癌均为病理证实，经支架引流术后病人的退黄显效率60．41％、支架平均引流186d，6个月支架阻塞率55．80％。结论 ERCP是诊断和治疗十二指肠乳头癌的有效方法。     

经内镜逆行胆管引流治疗梗阻性黄疸影响因素分析

目的 探讨经内镜逆行胰胆管造影（ERCP）+鼻胆管引流术（ENBD）和（或）胆道内支架植入术（ERBD）治疗梗阻性黄疸的影响因素。方法 回顾性分析2016年1月至2018年12月广州医科大学附属第二医院收治的成功施行ERCP+ENBD和（或）ERBD治疗的379例梗阻性黄疸病例资料。共实施ERCP 435例次,其中术后退黄不理想为74例次（17.0%）。结果 单因素分析结果显示,恶性肿瘤（χ2=24.502,P=0.000）、重度黄疸（χ2=6.738,P=0.009）,合并乙肝肝硬化（χ2=18.010,P=0.000）、自身免疫性肝病（χ2=5.484,P=0.019）、合并肝吸虫病（χ2=4.788,P=0.029）、引流方式（χ2=9.685,P=0.021）、黄疸病程时间较长≥2周（χ2=26.103, P=0.000）、术后胆道感染（χ2=10.463,P=0.001）是影响ERCP术后退黄效果的因素。多因素分析结果显示,恶性肿瘤（OR=3.675,P=0.000）、乙肝肝硬化（OR=3.685,P=0.001）、自身免疫性肝病（OR=12.308,P=0.004）、肝吸虫病（OR=6.591,P=0.000）、黄疸持续时间≥2周（OR=2.620,P=0.001）及术后胆道感染（OR=5.865,P=0.016） 是ERCP术后黄疸下降不理想的独立影响因素。 随访2个月,大部分病例经过针对性治疗后黄疸症状改善明显。 结论 恶性肿瘤、乙肝肝硬化、自身免疫性肝病、合并有肝吸虫病、黄疸病程时间较长（≥2周）和术后胆道感染是ERCP治疗梗阻性黄疸病人术后退黄不理想的独立影响因素。