Choledochoscopy in common bile duct surgery for choledocholithiasis: A must: Eight years experience in 441 consecutive patients

Between 1975 and 1983, 441 choledochoscopy were performed in a series of 451 consecutive patients undergoing surgical common biliary duct exploration for choledocholithiasis. In 127 patients (27.8%), no stones were found. Forty-five cases (10%) of choledocholithiasis missed by surgical and radiologic exploration methods were found by choledochoscopy. Therefore the retained stone rate decreased from 10 per cent to 2 per cent. Fourteen patients (3%) died at surgery, ten of whom (2%) were over 70. Postoperative biliary tract was drained in 98 patients (8%) using external drainage. Biliary tract patency was checked on the tenth postoperative day by the tube cholangiography. When retained stones were not found, T-tube was removed on the 20th day after surgery. When retained stones were found (11 patients, 2%) an endoscopic papillotomy was performed. Choledochoscopy is a significant addition in biliary surgery. It reduces operative mortality and morbidity, decreases retained stone rate, diminishes indications for biliary anastomosis and sphincterotomy, and is easy to perform without specific training. Its extensive and systematic use is advocated when- ever common bile duct patency has to be surgically demonstrated in choledocholithiasis.     

OPERATIVE CHOLANGIOGRAPHY: EVALUATION OF ITS ROUTINE USE IN 569 CHOLECYSTECTOMIES1

From 1974 till 1979, 569 cholecystectomies with routine operative cholangiography were performed in the university surgical unit, Kwong Wah Hospital, Hong Kong, for non-malignant diseases of the gallbladder. Gallstones were present in 522 cases. Acalculous cholecystitis occurred in 47 cases. At least one of the clinical or operative indications to explore the common bile duct was present in 312 of the patients. However, in this group of patients in whom routine operative cholangiography was done, exploration of the common bile duct was performed in only 147, thus avoiding unnecessary exploration of the duct in 165 cases (52.8%). In the remaining 257 patients in whom there was no indication to explore the common bile duct, operative cholangiography revealed unexpected stones in the common bile duct in 14 (5.5%). After choledochotomy, post exploratory operative T-tube cholangiography was performed to rule out overlooked stones, which were present in six cases (6/161, i.e., 3.7%). Postoperative T-tube cholangiography performed on the 12th to the 14th postoperative day showed retained stones in 17 cases, giving an incidence of known retained stones of 11% (17/161) of cholecystectomies with exploration of the common bile ducts, or 3% (17/569) in the whole series of     

Laparoscopic common bile duct exploration.

Operative common bile duct exploration, performed in conjunction with cholecystectomy, has been considered the treatment of choice for choledocholithiasis in the presence of an intact gallbladder. With the advent of laparoscopic cholecystectomy, the management of common bile duct stones has been affected. More emphasis is being placed on endoscopic sphincterotomy and options other than operative common duct exploration. Because of this increasing demand, we have developed a new technique for laparoscopic common bile duct exploration performed in the same operative setting as laparoscopic cholecystectomy. A series of five patients who successfully underwent common bile duct exploration, flexible choledochoscopy with stone extraction, and T-tube drainage, all using laparoscopic technique, is reported. Mean postoperative length of hospital stay was 4.6 days. Outpatient T-tube cholangiography was performed in all cases and revealed normal ductal anatomy with no retained stones. Follow-up ranged from 6 weeks to 4 months, and all patients were asymptomatic and had normal liver function tests.     

The importance of postoperative choledochoscopy for management of retained biliarytract stones

From 1974-8, 808 postoperative choledochoscopy procedures, conducted by insertion of choledochofiberscope into the biliary tract through the sinus tract after the T-tube had been removed, were carried out in 292 patients at Teikyo University Hospital, Tokyo, Japan. In this series, 104 with retained biliary tract stones were encountered, and complete removal of stones was successfully carried out in 101, using postoperative choledochoscopy. Any failures of removal of retained biliary tract stones were attributed to improper insertion of the T-tube. The T-tube, of at least 18 French calibers should be inserted into the common bile duct at a right angle so as to obviate a tortuous sinus tract. The follow-up study in cases of complete extraction of the retained biliary tract stones showed that this approach is most effective. Recurrent stone with a silk nidus was found in one patient in whom postoperative choledochoscopy had been performed one year previously. Reoperation was carried out in this particular case. All other patients have remained asymptomatic. Finally, we advise routine use of postoperative choledochoscopy as an adjunct to the T-tube cholangiography, in order to prevent the possibility of retained biliary tract stones. Contents of this paper were read before the Annual Meeting of the American Society for Gastrointestinal Endoscopy, Digestive Disease Week '79 on May 22nd, 1979 in New Orleans, U.S.A.     

Percutaneous flexible choledochoscopy: a simple method for retained common bile duct stone removal

Conventional methods of treatment of retained common bile duct stones found on T tube cholangiography after common bile duct exploration include percutaneous extraction under fluoroscopic control and endoscopic sphincterotomy. Four cases of percutaneous stone extraction under direct vision using the flexible choledochoscope are described. Clearance of the bile ducts was achieved at one sitting in three cases and four sittings in one case. Follow-up tube cholangiography was performed in two cases and confirmed complete clearance. Percutaneous endoscopic stone extraction can be performed by any surgeon with experience of flexible choledochoscopy and offers the advantages of a minimally invasive procedure without the use of specialized equipment.     

胆总管结石残留的因素分析及防治

目的 探讨胆囊结石胆囊切除术后胆总管结石残留的原因及处理方法。方法 1994年1月2000年9月间1027例胆囊结石病人在我院施行胆囊切除术,同时行胆总管切开探查术者246例,证实有胆总管结石者205例;对其中14例术后胆总管结石残留患者的临床资料进行对比分析。结果 结石残留组病人的76％为60岁或以上,64％并发急性胆管炎,50％术中取出胆总管结石3－5枚,仅14％行术中纤维胆道镜探查取石,与无结石残留病人相比差异均有显著性意义（P＜0．05）。13例残留结石经术后胆总管T管造影发现并分别行1－2次术后纤胆镜取石后完全清除;另1例自然排出。结论 胆总管结石残留多发生于年龄较大、胆总管结石较多、并发急性胆管炎的患者;术中纤胆镜的应用有助于防止结石残留。胆总管T管造影能可靠地诊断残留结石。术后经T管瘘道纤胆镜取石是治疗残留结石安全有效的方法。     

术后胆道镜取石1226例体会

目的探讨经T管窦道胆道镜取石的方法及技巧,评价胆道镜在肝内外胆管结石治疗中的价值。方法回顾分析我院1990年3月至2011年9月术后胆道镜取石1226例,结石取净后常规行T管造影。结果共取石2685次,平均2.2次,取石最多次数者为12次。取净1182例,取净率96.4%。除1例为了重新放置T管而扩张窦道时引起出血、2例取石过程中引起窦道破裂外,未发生其它严重并发症。结论术后胆道镜取石,作为胆道结石特别是肝胆管结石治疗环节中不可或缺的一环,在胆道结石治疗中扮演着十分重要的角色。     

Operative common bile duct imaging by operative cholangiography and flexible choledochoscopy.

A consecutive series of 108 common bile duct (CBD) explorations was studied to examine the efficacy of routine operative cholangiography and flexible choledochoscopy in the identification of choledocholithiasis. CBD exploration was performed according to the findings of routine operative cholangiography. Nine negative explorations were performed, only one of which would have been avoided had selective cholangiography been employed. Eight patients had unsuspected choledocholithiasis that would have been missed if selective operative cholangiography had been used. Flexible choledochoscopy identified CBD stones on 97 occasions; no additional retained stones were found on subsequent T tube cholangiography. In two cases stones were seen but could not be removed; immediate identification allowed planning for early removal. Flexible choledochoscopy is the most effective method of CBD exploration and should be used in all patients with suspected choledocholithiasis.     

Early postoperative endoscopic sphincterotomy for retained common duct stones

The results of endoscopic sphincterotomy in 30 patients with retained common bile duct stones and a T-tube in situ following surgical exploration of the common bile duct are presented. Successful stone extraction was achieved in 27 cases (90%). There was one death, which was not procedure related. Early postoperative T-tube cholangiography is advocated and if necessary sphincterotomy can be safely performed 1 week following surgery. This approach has advantages in shortening hospital stay and minimising patient discomfort.     

腹腔镜胆总管切开取石术T管处理的探讨

目的探讨腹腔镜胆总管切开取石术后T管的处理方法。方法1997年7月-2004年10月，我院行腹腔镜胆总管切开取石（laparoscopic common bile duct exploration，LCBDE）、置T管治疗肝外或肝外合并肝内胆管结石420例。明确有胆总管结石后，胆总管切开取石，胆总管一期缝合或置T管。结果胆总管切开取石一期缝合27例（6．4％），置T管393例（93．6％）。术中取尽结石236例（56．2％），术后胆道镜取石184例（43．8％）。209例术后3-4周行经T管胆道造影，无残余结石，拔除T型管。420例随访3个月-6年。平均47．5月，3例复发。结论腹腔镜胆总管切开取石术后T管拔管时间，T管造影无残留结石拔管时间应3—4周，T管造影有残留结石，应于术后6周胆道镜取石后拔管，均闭管2周。     

TECHNIQUE AND RESULTS OF LAPAROSCOPIC CHOLEDOCHOTOMY FOR THE MANAGEMENT OF BILE DUCT CALCULI

Laparoscopic choledochotomy has been performed in 50 patients to remove common bile duct calculi demonstrated on routine operative cholangiography at the time of laparoscopic cholecystectomy. The patients ranged from 16 to 91 years old. One patient died, giving a mortality of 2%. At postoperative T-tube cholangiography, retained stones were demonstrated in three patients (6%) with all stones being removed using a choledochoscope via the T-tube track. Laparoscopic common bile duct exploration via a choledochotomy is a feasible and effective method to manage common bile duct calculi demonstrated during laparoscopic cholecystectomy.     

胆囊结石合并胆总管结石260例报告

目的总结腹腔镜胆囊切除联合胆总管探查术(laparoscopic common bile duct exploration,LCBDE)治疗胆囊结石合并胆总管结石的经验。方法 2005年1月~2008年5月对260例胆囊结石合并胆总管结石行腹腔镜胆囊切除联合LCBDE,全麻后平卧位,采用四孔法。游离胆囊管及胆囊动脉后施血管夹后夹闭,显露胆总管,电凝钩切开胆总管长度约1.5~2.5 cm,取出胆管结石放置于标本袋内,胆道镜检查无结石残留,置入T管于胆总管内间断缝合固定。切除胆囊,取出胆囊、标本袋,经T管注水检查无渗漏,放置腹腔引流,缝合切口。结果成功254例,成功率97.7%(254/260),手术时间70~230 min,平均126 min。中转开腹6例:3例因胆囊三角纤维化严重,呈"冰冻状",无法解剖而中转开腹;1例术中证实Mirizzi综合征而中转开腹;1例因结石嵌顿于胆总管下段无法镜下取出而中转开腹;1例剥离胆囊床时位置靠深,损伤肝中静脉分支,出血汹涌而中转开腹。术后3例出现胆漏,经保守治疗后2~6 d痊愈。1例胆管充满泥沙样结石术后并发寒战、高热,体温高达41.0℃,抗感染、对症治疗体温正常。1例术后3周经T管造影检查证实残留结石1枚,8周后经窦道用胆道镜取出结石。254例术后住院时间6~19 d,平均9 d。223例随访13~24个月,平均16个月,无胆道狭窄等并发症出现,1例术后22个月出现腹痛、黄疸、高热,MRCP证实胆道结石复发,经EST取出结石。结论严格筛选病例,熟练掌握软硬镜技术及细致的术中操作是开展此手术的关键。     

Radiological treatment of retained bile duct stones following recent surgery using glucagons

BACKGROUND: Retained common bile duct (CBD) stones pose an occasional problem following ductal exploration, in spite of completion cholangiography or choledochoscopy. We present a method for treating retained stones in the Radiology Department by biliary lavage via a transcystic tube (TCT) or a T-tube, after intravenous administration of glucagon. METHODS: A TCT or T-tube is inserted following CBD exploration for multiple intrahepatic stones or when stones are fragmented to facilitate removal or flushing into the duodenum. A tube cholangiogram is performed on the 1st postoperative day. If any retained stones are encountered, 1 mg glucagon is administered intravenously and saline irrigation through the tube is done under fluoroscopic control, allowing the stone to pass to the duodenum. The cholangiogram is repeated 10-14 days later, before removing the tube. RESULTS: In case 1, transcystic CBD exploration was performed. Two stones were crushed and flushed into the duodenum. TCT cholangiography the following day. showed a 5-6-mm fragment causing complete obstruction. Following the use of glucagon and irrigation, the stone was observed passing into the duodenum, causing a brief mild episode of pain. In case 2, laparoscopic choledochotomy was performed to remove seven large stones. Completion choledochoscopy was satisfactory. T-tube cholangiography identified a small stone in the CBD, which was cleared with the help of glucagon. CONCLUSION: The current standard treatment for retained stones is endoscopic sphincterotomy. This is associated with morbidity, mortality, and significant additional cost. This new technique is a simple and safe alternative for retained CBD stones, most of which as small stones or fragments. Because glucagon causes intense relaxation of the sphincter of Oddi, the procedure should not take much longer than a routine tube cholangiogram. The safety of glucagon makes it possible to repeat the procedure if necessary.     

Choledochoscopy and common bile duct exploration

Common bile duct (CBD) exploration is often indicated when cholecystectomy is performed for gallstone disease. Choledochoscopy may help to decrease the incidence of retained common duct stones. The present study reviews 97 consecutive CBD exploration cases performed between 1980 and 1988, in order to evaluate the authors' experience with flexible choledochoscopy and CBD exploration. Fifty-nine patients had CBD exploration plus flexible choledochoscopy and 38 underwent CBD exploration alone. Retained stones were found postoperatively in ten per cent of the patients who had only CBD exploration versus four per cent in the choledochoscopy group. The retained stones in five patients were later removed by percutaneous basket retrieval (3), flush irrigation (1), and choledochoscopy (1). Flexible choledochoscopy detected additional stones after routine CBD exploration in 12 patients, clarified T-tube cholangiograms in four patients, and aided stone extraction in two patients. For these reasons, and because choledochoscopy was associated with a lower incidence of retained stones, the authors believe this procedure is a worthwhile addition in most cases of CBD exploration.     

胆总管探查后一期缝合的经验和认识

目的 探讨胆总管探查后一期缝合的经验和认识。方法对1990年1月至2004年6月因肝外胆管结石择期行胆总管探查后一期缝合的271例作一回顾性分析。所有病例不含肝内胆管结石，术中经胆道镜或胆道造影排除胆道残石并常规放置右肝下引流管。结果术后14例腹腔引流液含胆汁，均未特殊处理。术后平均住院8．73d。所有病例术后3个月内门诊B超复查，未发现胆道残石。216例（79．70%）获得远期随访，无一例发现肝外胆管狭窄。结论对经过严格选择的肝外胆管结石病例，胆总管探查后不应强调一律放置T管。术中精细操作和经术中胆道镜或胆道造影检查排除残石后，一期缝合可作为术式选择。     

Operative choledochoscopy in patients with acute cholangitis: a prospective, randomized study

A prospective, randomized evaluation of operative choledochoscopy was carried out during emergency surgery in patients with acute cholangitis or acute suppurative cholangitis when conservative management had failed. After common bile duct exploration, 79 patients were randomized to have choledochoscopy and 78 patients to the control group. Laboratory and clinical parameters showed that choledochoscopy did not increase the incidence of septicaemia, acute pancreatitis, persistent cholangitis, postoperative wound sepsis, intraperitoneal sepsis and hospital mortality. The incidence of retained common bile duct stones detected by T tube cholangiography performed in the second postoperative week was significantly reduced (P less than 0.01) after choledochoscopy. Choledochoscopy detected stones missed by conventional common bile duct exploration in ten patients. It is concluded that choledochoscopy is a safe and effective technique in patients with acute cholangitis and acute suppurative cholangitis.     

Choledochoscopy in exploration of the common bile duct

The technique of operative fibreoptic choledochoscopy is described; the results are reported in 88 patients with gallstones requiring exploration of the common bile duct. There were no cases of retained calculi that were endoscopically undetected. Postoperative T-tube cholangiography was carried out in 81 cases and confirmed the findings of operative biliary endoscopy in all cases. Choledochoscopy is an accurate and safe operative procedure which can eliminate the problem of undetected residual calculi.     

Operative choledochoscopy in common bile duct surgery.

Surgical exploration of the common bile duct for gallstones is a common operation but carries a high residual stone rate. Conventional techniques for exploring the bile ducts are blind procedures. The surgeon cannot see what he is doing. Also there has been no reliable method for a postexploratory check of the bile ducts before closure, usually around a T-tube. Operative choledochoscopy allows the surgeon to see stones in the duct, may aid the removal of stones and provides visual postexploratory checks that the common bile duct and the hepatic ducts are clear, that papilla is patent and that no stone is left behind before closure. A personal series of 150 patients had operative choledochoscopy using a flexible fibreoptic choledochoscope. If there was a clear indication on preoperative investigations that the ducts should be explored, an operative cholangiogram was omitted and the choledochoscope used as the exploring instrument. In 127 patients with a diagnosis of gallstone disease, choledochoscopy was used at the primary operation. In 12 patients choledochoscopy was used at a secondary operation for recurrent gallstone disease, and 11 patients had malignant obstruction of the biliary tract. In 70 of the 127 patients, gallstones were found and extracted using the choledochoscope. In 53 patients the ducts were clear, and in 4, other lesions were found: 3 papillomas and one polycystic disease. One hundred and six of the patients had the common bile duct closed primarily with no T-tube drainage. There was no increase in complications and no deaths associated with choledochoscopy or primary closure of the common bile duct.(ABSTRACT TRUNCATED AT 250 WORDS)     

Experience with the Flexible Fiberoptic Choledochoscope

Despite significant effort on the part of surgeons, the incidence of retained calculi after common duct exploration still remains unacceptably high. It seems likely that the best way to reduce the incidence of retained calculi would be a more complete exploration of the common duct at the time of the initial operation. We report our experience with a flexible fiber optic endoscope used intraoperatively in 52 patients and postoperatively in one case to visualize the intrahepatic and extrahepatic bile ducts. In addition to visualization of stones, the choledochoscope has a channel through which various instruments can be passed to facilitate stone removal. Flexible choledochoscopy has been performed 53 times in 52 patients between July 1978 and November 1980. In one patient, the choledochoscope was used to explore the bile ducts via the T-tube tract after operation. In 52 patients, the scope was used intraoperatively: a) two patients demonstrated bile duct tumors, b) in 14, stones were not found on exploration. Of these, one had stenosis at the papilla of Vater and one had external compression of the duct by a pancreatic pseudocyst. All of these findings were confirmed by choledochoscopy, c) in 26 patients choledochoscopy confirmed complete surgical removal of all stones, d) in six patients, multiple stones were removed using routine common duct exploration but additional stones were seen with the choledochoscope, e) in three patients no stones were retrieved on routine duct exploration but were seen using the choledochoscope. In groups (d) and (e) the scope facilitated removal of the remaining stones. In eight cases stones were either grasped or crushed using the accessories of the choledochoscope. In one patient calculi were missed both by routine surgical exploration and choledochoscopy. No septic complications were seen in any of these patients.     

Choledochoscopy during biliary surgery for reducing the risk of overlooked stones

Summary Although cholangiography is routinely performed during biliary surgery to ensure the removal of all stones, it is not always successful. Some investigators have claimed that intraoperative choledochoscopy is more effective in detecting all stones, although reports on the efficacy of this method have been contradictory. Furthermore, no study has systematically examined either of these procedures in terms of the actual incidence of overlooked stones. Thus, to evaluate the merits of intraoperative cholangiography as opposed to choledochoscopy, we studied the incidence of overlooked bile duct stones after surgery. We investigated 126 patients who had undergone surgery during which choledocholithotomy was performed within the past 10 years; 117 of these cases involved common bile duct stones and 22, intrahepatic stones. After the exclusion of 13 subjects whose stones were deliberately left for postoperative treatment due to severe complications, 126 patients were finally analyzed. Overlooked stones were found postoperatively in 13 (10%) of these 126 subjects, including 11 (14%) of 63 patients who had been inspected by intraoperative cholangiography alone and 2 (3%) of 63 who had undergone both choledochoscopy and cholangiography during surgery. Therefore, the incidence of overlooked stones proved to be significantly lower in those who had undergone choledochoscopy combined with cholangiography (P <0.01). Our results suggest the value of combining choledochoscopy with cholangiography during surgery for reducing the risk of overlooked bile duct stones.