Role of Preoperative Endoscopic Retrograde Cholangiography in Laparoscopic Cholecystectomy

Abstract: An endoscopic retrograde cholangiography (ERC) was performed in 303 patients before laparoscopic cholecystectory. The ERC was successful in 275 patients (90.8%). Common bile duct stones were diagnosed in 9 of 275 patients (3.3%). These had not been suspected on the basis of the clinical and laboratory data or ultrasonography results in 8 of them. An endoscopic papilotomy (EPT) was successful in all 9 patients with choledocholithiasis before laparoscopic cholecystectomy. Anatomical variations, such as origin of the cystic duct from the right or left hepatic duct and an accessory bile duct, were detected in 6 patients (2.2%). Preoperative ERC proved useful in determining the biliary anatomy or detecting unsuspected stones. (Dig Endosc 1994; 6 : 24–27)     

Sphincterotomy in patients with gallstones, elevated LFTs and a normal CBD on ERCP

BACKGROUND/AIMS: To determine whether an endoscopic sphincterotomy affects outcome in patients with symptomatic gallstones, elevated liver function tests and a normal common bile duct on endoscopic retrograde cholangiopancreatogram. METHODOLOGY: A total of 163 patients with symptomatic gallstones and elevated liver function tests, and found to have a normal common bile duct on endoscopic retrograde cholangiopancreatogram were included in the study. Endoscopic sphincterotomy was performed in 78 (47.8%) patients, while 85 (52.1%) patients did not have an endoscopic sphincterotomy. The two groups were compared for detection of small unseen common bile duct stones/debris, endoscopic retrograde cholangiopancreatogram related complications, and biliary complications after cholecystectomy. RESULTS: Small common bile duct stones/debris were recovered in 11/43 (25.5%) patients who had instrumentation of the common bile duct performed after endoscopic sphincterotomy. Common bile duct instrumentation was not performed in any of the patients without endoscopic sphincterotomy. No patient had any biliary complication after cholecystectomy, both in the immediate postoperative period and on a follow-up of 37.5 +/- 13.6 months (range 17-66). Endoscopic retrograde cholangiopancreatogram related complications occurred in 8 patients who had an endoscopic sphincterotomy and in 2 without endoscopic sphincterotomy (p < 0.05). CONCLUSIONS: Performing an endoscopic sphincterotomy in these patients increases the detection of small unseen common bile duct stones/debris without changing the clinical outcome after cholecystectomy. It also increases the endoscopic retrograde cholangiopancreatogram related complication rate, and therefore may not be necessary.     

Routine intravenous cholangiography, selective ERCP, and endoscopic treatment of bile duct stones before laparoscopic cholecystectomy.

BACKGROUND: No procedure has yet been identified as the standard for the detection and management of choledocholithiasis in patients undergoing laparoscopic cholecystectomy. METHODS: A prospective study involved 1305 patients undergoing elective laparoscopic cholecystectomy. Intravenous cholangiography was performed on all patients except those with jaundice or cholangitis, acute pancreatitis, or allergy to contrast material. Patients underwent endoscopic retrograde cholangiography (ERC) and endoscopic sphincterotomy when there was a strong suspicion of choledocholithiasis, positive or inconclusive findings on intravenous cholangiography or allergy to contrast material with signs of possible choledocholithiasis. Intraoperative cholangiography was performed when patients did not undergo ERC or intravenous cholangiography and whenever the surgeon was in doubt about biliary anatomy or biliary clearance. RESULTS: Two hundred thirty-one patients (17.7%) were referred for preoperative ERC; 14 of them were referred for open surgery because of failure of ERC or sphincterotomy. Only 54 patients underwent intraoperative cholangiography. Bile duct stones, detected in 186 cases (14.2%) (68 of which were asymptomatic), were removed before surgery in 162 cases (87.1%) and during surgery in 20 (10.7%). Self-limited pancreatitis occurred in 3.6% of the patients after sphincterotomy. Laparoscopic cholecystectomy was performed in 98.7% of the cases. The conversion rate was 8% if sphincterotomy had been performed previously, and 3% after standard laparoscopic cholecystectomy (p < 0.001). The morbidity rate was 5% and the mortality rate 0.08%. During the follow-up period 4 patients had retained stones that were treated endoscopically. CONCLUSIONS: Preoperative ERC followed by laparoscopy is the best approach to treatment of patients with cholecystolithiasis and suspected choledocholithiasis.     

Gallstone disease. Management of common bile-duct stones and associated gallbladder stones: Surgical aspects

For many years, open exploration of the common bile duct has been the treatment of choice for patients with common bile-duct stones. During recent decades endoscopic sphincterotomy has gained wide acceptance as an effective and less invasive alternative. After sphincterotomy, subsequent (laparoscopic) cholecystectomy is warranted in patients with gallbladder stones. This chapter will discuss whether sphincterotomy should be performed prior to, during or after cholecystectomy, and will also address the question of whether single-stage treatment by laparoscopic cholecystectomy and laparoscopic bile-duct exploration is in fact preferable. The rate of recurrent choledocholithiasis after endoscopic biliary sphincterotomy can reach more than 20%. This review focuses on the risk factors--delayed bile-duct clearance and bactobilia--that may lead to recurrent primary bile-duct stone formation. Underlying altered bile composition (relative phospholipid deficiency) should be recognised in a subgroup of patients. Identification of these risk factors may significantly affect treatment policy.     

Laparoscopic cholecystectomy and intraoperative endoscopic sphincterotomy in the treatment of cholecysto-choledocholithiasis.

BACKGROUND: A single-stage minimally invasive procedure would be optimal for management of cholecysto-choledocholithiasis. Two alternative strategies are available: management by laparoscopy alone or a combined laparoscopic-endoscopic approach. This study evaluates the results of the latter procedure. METHODS: From June 1993 to September 1997, 1400 patients with symptomatic biliary stone disease were evaluated for laparoscopic cholecystectomy. Intraoperative cholangiography was performed on the basis of a preoperative suspicion of bile duct stones; bile duct stone treatment was by intraoperative endoscopic retrograde sphincterotomy. RESULTS: Intraoperative cholangiography was performed because of a preoperative suspicion of a bile duct abnormality in 141 of 1400 patients (10%) undergoing laparoscopic cholecystectomy because of biliary stone disease. Of those 141 patients, 54 (38.3%) presented with pathologic findings (bile duct stone [52] and papillary stenosis [2]); all 54 underwent intraoperative endoscopic sphincterotomy. Complete clearance of the ductal stones was achieved in 43 patients (82.7%) by intraoperative sphincterotomy, and in 9 patients by an additional postoperative endoscopic procedure. Laparoscopic cholecystectomy was carried out in all cases. There were no conversions to an open operation. Postoperative course in the uncomplicated cases was comparable to that for laparoscopic cholecystectomy alone. The postoperative complication rate was 5.6% and mortality 1.8%. Mean hospital stay was 3.3 days (range 2 to 16). At a mean 38 months follow-up, no complications related to the laparoscopic-endoscopic procedure were observed. CONCLUSION: The intraoperative combined laparoscopic-endoscopic approach seems to be a feasible and effective management of cholecysto-choledocholithiasis, saving patients a subsequent invasive procedure.     

Early postoperative endoscopic sphincterotomy for retained common bile duct stones

Endoscopic sphincterotomy was performed within 28 days after cholecystectomy in 20 patients with retained common bile duct stones, of whom 15 (75%) underwent endoscopic sphincterotomy within the first week of surgery. Stone extraction was successful in all patients and no immediate complications were noted. Early endoscopic sphincterotomy for retained common bile duct stones was safe and effective in the early postoperative period.     

Cholecystectomy or gallbladder in situ after endoscopic sphincterotomy and bile duct stone removal in Chinese patients

BACKGROUND & AIMS: In patients with stones in their bile ducts and gallbladders, cholecystectomy is generally recommended after endoscopic sphincterotomy and clearance of bile duct stones. However, only approximately 10% of patients with gallbladders left in situ will return with further biliary complications. Expectant management is alternately advocated. In this study, we compared the treatment strategies of laparoscopic cholecystectomy and gallbladders left in situ. METHODS: We randomized patients (>60 years of age) after endoscopic sphincterotomy and clearance of their bile duct stones to receive early laparoscopic cholecystectomy or expectant management. The primary outcome was further biliary complications. Other outcome measures included adverse events after cholecystectomy and late deaths from all causes. RESULTS: One hundred seventy-eight patients entered into the trial (89 in each group); 82 of 89 patients who were randomized to receive laparoscopic cholecystectomy underwent the procedure. Conversion to open surgery was needed in 16 of 82 patients (20%). Postoperative complications occurred in 8 patients (9%). Analysis was by intention to treat. With a median follow-up of approximately 5 years, 6 patients (7%) in the cholecystectomy group returned with further biliary events (cholangitis, n = 5; biliary pain, n = 1). Among those with gallbladders in situ, 21 (24%) returned with further biliary events (cholangitis, n = 13; acute cholecystitis, n = 5; biliary pain, n = 2; and jaundice, n = 1; log rank, P = .001). Late deaths were similar between groups (cholecystectomy, n = 19; gallbladder in situ, n = 11; P = .12). CONCLUSIONS: In the Chinese, cholecystectomy after endoscopic treatment of bile duct stones reduces recurrent biliary events and should be recommended.     

Selective use of perioperative ERCP in patients undergoing laparoscopic cholecystectomy

BACKGROUND/AIMS: Management of common bile duct stones in the era of laparoscopic surgery is still controversial. The purpose of this study is to investigate the safety, feasibility, success rate and short-term results of the selective use of endoscopic retrograde cholangiopancreatography in patients undergoing laparoscopic cholecystectomy. METHODOLOGY: A prospective study comprising 300 consecutive patients with either symptomatic or complicated gallbladder stones was performed between January 1994 and November 1996. Depending on clinical, laboratory and ultrasonographic criteria, 73 patients (24.3%) underwent endoscopic retrograde cholangiopancreatography with or without endoscopic sphincterotomy. The procedure was successful in 71 patients (97%) either preoperatively in 62 patients (21%) or postoperatively in 9 patients (3%). RESULTS: Endoscopic retrograde cholangiopancreatography was positive in 37 cases (52%), endoscopic sphincterotomy and stone extraction was performed in 35 cases and endoscopic sphincterotomy alone was performed in 2 cases for benign papillary stenosis. The overall predictive value for the presence of common bile duct stone was 52%, the predictive value for patients with jaundice, dilated common bile duct together with elevated liver enzymes was 73.3%. Complications of perioperative endoscopic retrograde cholangiopancreatography were encountered in 4 patients (5.5%) with no mortality. CONCLUSIONS: We conclude that the combination of perioperative endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy is a useful approach for the management of choledochocholelithiasis.     

Echo-endoscopy versus endoscopic retrograde cholangiography for the diagnosis of choledocholithiasis: the influence of the size of the stone and diameter of the common bile duct

BACKGROUND: Endoscopic retrograde cholangiography is highly accurate in diagnosing choledocholithiasis, but it is the most invasive of the available methods. Endoscopic ultrasonography is a very accurate test for the diagnosis of choledocholithiasis with a risk of complications similar to that of upper gastrointestinal endoscopy. AIM: To compare the accuracy of endoscopic ultrasonography and endoscopic retrograde cholangiography in the diagnosis of common bile duct stones before laparoscopic cholecystectomy and to analyze endoscopic ultrasound results according to stone size and common bile duct diameter. PATIENTS AND METHODS: Two hundred and fifteen patients with symptomatic gallstones were admitted for laparoscopic cholecystectomy. Sixty-eight of them (31.7%) had a dilated common bile duct and/or hepatic biochemical parameter abnormalities. They were submitted to endoscopic ultrasonography and endoscopic retrograde cholangiography. Sphincterotomy and sweeping of the common bile duct were performed if endoscopic ultrasonography or endoscopic retrograde cholangiography were considered positive for choledocholithiasis. After sphincterotomy and common bile duct clearance the largest stone was retrieved for measurement. Endoscopic or surgical explorations of the common bile duct were considered the gold-standard methods for the diagnosis of choledocholithiasis. RESULTS: All 68 patients were submitted to laparoscopic cholecystectomy with intraoperative cholangiography with confirmation of the presence of gallstones. Endoscopic ultrasonography was a more sensitivity test than endoscopic retrograde cholangiography (97% vs. 67%) for the detection of choledocholithiasis. When stones >4.0 mm were analyzed, endoscopic ultrasonography and endoscopic retrograde cholangiography presented similar results (96% vs. 90%). Neither the size of the stone nor the common bile duct diameter had influence on endoscopic ultrasonographic performance. CONCLUSIONS: For a group of patients with an intermediate or moderate risk with respect to the likelihood of having common bile duct stones, endoscopic ultrasonography is a better test for the diagnosis of choledocholithiasis when compared to endoscopic retrograde cholangiography mainly for small-sized calculi.     

The management of bile duct stones.

Bile duct stones are almost always associated with gallbladder stones and coexist with gallbladder stones in approximately 10% of patients. The frequency of coexisting bile duct stones increases with advancing age. In patients with stones in both the gallbladder and bile duct, therapeutic options for the latter include laparoscopic or open exploration of the bile duct, and pre-operative and post-operative endoscopic sphincterotomy and stone extraction. Endoscopic sphincterotomy remains the treatment of choice for bile duct stones after cholecystectomy. However, management algorithms in individual institutions will be influenced by surgical and endoscopic expertise and by other factors such as overall costs. After surgical or endoscopic removal of bile duct stones, estimates of the lifetime risk of recurrent stones range from 5%-20%. Increased life expectancy and the apparent absence of simple preventative measures indicate that the burden of bile duct stones on health expenditure is likely to increase in many countries.     

胆管腔内超声与逆行胆管造影诊断胆管结石的对比研究

目的 比较十二指肠镜下胆管腔内超声（IDUS）和内镜下逆行胆管造影（ERC）诊断肝外胆管结石的作用。方法 对30例临床怀疑有肝外胆管结石的患者，先进行ERC，再经内镜活检孔道将超声微探头直接送入胆管腔内探查，而后行乳头切开取石。结果 30例患者中，ERC准确诊断结石26例，将胆管絮状物诊断为结石1例，漏诊2例，其诊断结石的准确率，敏感性分别为86.7%(26/30),92.9%(26/28)；而IDUS准确诊断结石28例，无漏诊，误诊，其诊断结石的准确率，敏感性均为100.0%。结论 IDUS可弥补ERC的视觉误差且在确定胆管结石方面优于ERC。     

内镜扩约肌切开术治疗胆总管继发性结石

目的评价逆行胰胆管造影术（ＥＲＣＰ）和内镜括约肌切开术（ＥＳＴ）在腹腔镜胆囊切除前后诊断和治疗胆总管继发结石中的作用．方法采用ＥＲＣＰ和ＥＳＴ在ＬＣ术前或术后诊断和治疗胆总管继发结石２２８例,其中包括ＬＣ术前发现的１８５例和术后确诊的４３例．常规ＥＲＣＰ检查,证实胆总管内有结石后行ＥＳＴ．然后根据结石形态、大小和数目不同采取不同方法处理结石．①自然排石,适合于直径在０３ｃｍ～０８ｃｍ的结石;②取石网篮取石,适合于直径在０９ｃｍ～１５ｃｍ的结石;③碎石篮碎石,适宜直径大于１５ｃｍ以上的结石．结果全部２２８例患者中,ＥＳＴ成功２１７例（９５２％）,胆总管结石完全排出２０９例（９１７％）,发生各种并发症１９例（８８％）,主要并发症为急性胰腺炎、急性胆管炎和Ｏｄｄｉ扩约肌切口渗血,全部经非手术治疗愈合,无死亡病例．结论ＥＲＣＰ和ＥＳＴ是ＬＣ术前和术后诊治胆总管结石安全有效的方法之一．     

Surgical therapy for gallstone disease

Surgery, in particular laparoscopic cholecystectomy, will probably remain the preferred treatment for symptomatic gallbladder stones. It is unlikely that other methods of treatment, such as oral dissolution therapy or lithotripsy, can match the results and patient acceptance of this procedure. With the advent of laparoscopic cholecystectomy, however, more patients with choledocholithiasis will undergo endoscopic sphincterotomy and endoscopic common bile duct clearance. This may change, however, if the common bile duct can be explored safely through the laparoscope. Finally, severe gallstone pancreatitis will continue to be treated by early endoscopic sphincterotomy followed by cholecystectomy. Nevertheless, endoscopic sphincterotomy alone will be used more often as a definitive treatment to prevent recurrent attacks, especially in elderly patients who are poor candidates for cholecystectomy.     

Selective MRCP in the management of suspected common bile duct stones

Background. It is controversial whether selective endoscopic sphincterotomy or routine laparoscopic bile duct exploration is the optimal treatment for choledocholithiasis. Magnetic resonance cholangio-pancreatography (MRCP) is a safe and accurate imaging modality; this study evaluated its use in a clinical algorithm for the management of suspected choledocholithiasis. Patients and methods. Consecutive patients presenting with suspected common bile duct (CBD) stones were managed according to an algorithm involving the selective use of MRCP to identify patients who required endoscopic sphincterotomy and bile duct clearance. Following radiological demonstration of a clear CBD, all patients were considered for cholecystectomy. Results. From 157 consecutive patients, 68 proceeded straight to endoscopic sphincterotomy, which was therapeutic in 59. Of 89 who underwent MRCP, choledocholithiasis was demonstrated in 29; subsequent endoscopic sphincterotomy was therapeutic in 22. MRCP demonstrated a clear CBD in the remaining 60 patients. Seventy-four patients subsequently underwent cholecystectomy, with a conversion rate of 9% and a median postoperative stay of 1 day. There were no instances of post-sphincterotomy pancreatitis or haemorrhage requiring transfusion. Conclusion. An algorithm involving selective MRCP with endoscopic sphincterotomy is a safe, effective means of managing suspected choledocholithiasis, particularly where the expertise, equipment or theatre time for laparoscopic bile duct exploration is not routinely available.     

Endoscopy for bile duct stones

In the era of laparoscopic cholecystectomy and advanced non-invasive imaging studies, pre-operative endoscopic retrograde cholangiopancreatography (ERCP) for bile duct stones should be reserved for selected patients. ERCP remains the therapy of choice for removal of bile duct stones in the post-cholecystectomy patient and in patients with intact gallbladders. Bile duct stones can be cleared in nearly all patients using endoscopic techniques of sphincterotomy and mechanical lithotripsy. Difficult or complex bile duct stones can be endoscopically removed in the majority of patients with additional techniques such as extracorporeal shock wave lithotripsy, intraductal lithotripsy and/or stent placement. In non-operative patients in whom stone clearance cannot be achieved, long-term stent placement is a potential option in patients who are not candidates for further therapy. Endoscopic therapy may be effective in selected patients with intrahepatic biliary stones.     

Role of prophylactic endoscopic sphincterotomy in patients with acute biliary pancreatitis due to transient common bile duct obstruction

BACKGROUND AND AIM: The role of prophylactic endoscopic sphincterotomy in patients with transient common bile duct obstruction is controversial. The aim of this study was to assess the value of performing prophylactic endoscopic sphincterotomy in patients suffering from acute biliary pancreatitis and absent common bile duct stones on endoscopic retrograde cholangiopancreatography (ERCP). METHODS: Hospital notes of patients admitted to our unit with a diagnosis of acute pancreatitis from January 2000 to January 2005 were reviewed. Endoscopic sphincterotomy was performed when patients were deemed unfit for cholecystectomy, suffering from a severe attack of acute pancreatitis and/or showing evidence of transient common bile duct obstruction. The outcomes of patients with and without endoscopic sphincterotomy were compared. RESULTS: A total of 427 patients were admitted with a diagnosis of acute pancreatitis during the study period. Eighty-eight patients with absent common bile duct stones on ERCP were identified. Endoscopic sphincterotomy was performed in 71 patients and not performed in 17 patients. There was no significant difference in recurrent pancreatitis rates (1.4% vs 5.8%, P = 0.35), recurrent biliary complication rates (5.6% vs 5.9%, P = 1) or mortality rates (5.8% vs 1.5%, P = 0.35). The time to recurrent complications (38.4 days vs 41.0 days, P = 0.38) was not significantly different between the two groups. There was no ERCP-related morbidity or mortality. CONCLUSION: Prophylactic endoscopic sphincterotomy is not recommended in patients with transient common bile duct obstruction or as an option to cholecystectomy in elderly patients. Early cholecystectomy should be performed.     

Necessity of a repeat cholangiogram during biliary stent removal after postcholecystectomy bile leak

PURPOSE:

To assess the need for repeat endoscopic retrograde cholangiography (ERC) in patients undergoing biliary stent removal after management of postcholecystectomy bile leak.

METHODS:

A retrospective analysis of the Clinical Outcomes Research Initiative endoscopy database at PennState Milton S Hershey Medical Center (Hershey, Pennsylvania, USA) identified all patients referred for ERC with an indication of postcholecystectomy bile leak from January 2001 to June 2010. Baseline demographics, location of bile leak, size of biliary stent placed, duration of stenting, bile leak persistence, and the presence of stone, sludge or strictures on repeat ERC were analyzed.

RESULTS:

A total of 81 patients underwent ERC for management of bile leaks after cholecystectomy. One patient was excluded due to a complete transection of the common bile duct necessitating immediate surgical intervention. Fourteen (17.5%) patients underwent open cholecystectomy, 46 (57.5%) underwent laparoscopic procedures and 10 (12.5%) procedures were converted from a laparoscopic to an open approach intraoperatively. Of the 80 patients, 47 (58.7 %) had a cystic duct leak, 11 (13.7 %) had a right hepatic duct leak, 11 (13.7%) had a common bile duct leak, five (6.2%) had a gallbladder fossa leak, four (5%) had a common hepatic duct leak and the remaining two (2.5%) had a left hepatic duct leak. All 80 patients underwent biliary stenting as part of management for their bile leak. Fifty-seven of the 80 patients (71.2%) had a 10 Fr stent placed, with the remainder undergoing placement of a 7 Fr stent. Seventy-five (93.7%) patients underwent biliary sphincterotomy during the initial ERC. Sixty-nine patients underwent repeat ERC after a mean duration of 8.2 weeks (range 0.4 to 18.5 weeks). Eleven patients had no reviewable records regarding a repeat procedure performed for stent removal. Three patients required an early repeat ERC due to suspicion of cholangitis and, hence, were excluded from the final analysis. Of the 66 patients included in the final analysis, 61 (92.4%) had resolution of their bile leak on repeat ERC. All patients had resolution of their bile leak by the third ERC. Fifteen patients (22.7%) had an abnormality on repeat cholangiography (persistent leak in four, stones in three, sludge in seven, and a combination of leak and stone in one) that required further endoscopic intervention including balloon sweep or additional stenting.

CONCLUSION:

Although the majority of postcholecystectomy bile leaks resolve after biliary stent placement, a sizeable percentage (22.7%) of patients had abnormalities on subsequent cholangiograms that required further intervention. These findings suggest the need for a repeat ERC at the time of biliary stent removal in the management of postcholecystectomy bile leaks.     

Pre-operative endoscopic ultrasonography can optimise the management of patients undergoing laparoscopic cholecystectomy with abnormal liver function tests as the sole risk factor for choledocholithiasis: a prospective study

BACKGROUND: Pre-operative endosonography has been proposed as a cost-effective procedure in the management of patients who undergo laparoscopic cholecystectomy having an intermediate risk of common bile duct stones. We prospectively evaluated the impact of pre-operative endosonography on the management of patients facing laparoscopic cholecystectomy with abnormal liver function tests as the sole risk factor for choledocolithiasis. METHODS: Among 587 consecutive patients scheduled for laparoscopic cholecystectomy, 47 (8%) patients having one or more abnormal liver function tests but a normal appearance of common bile duct at abdominal ultrasound, underwent pre-operative endosonography. In patients with endosonography-detected common bile duct stones, a pre-operative endoscopic retrograde cholangiography was performed, or an intra-operative endoscopic retrograde cholangiography was scheduled. In all endosonography-negative patients, an intra-operative trans-cystic cholangiography was performed. RESULTS: Endosonography detected common bile duct stones in nine patients (19%) but only in five of them stones were radiologically confirmed (PPV 0.55). Endosonography-detected stones were confirmed in four of four (100%) patients in whom cholangiography was performed within 1 week, but only in one of five (20%) patients in whom radiology was further delayed (P < 0.05). In three of four cases (75%), stones detected at endosonography but not confirmed at X-rays, were smaller than 2.0 mm. Among 38 patients with negative endosonography, common bile duct stones were found in two patients (NPV 0.95), whereas unplanned endoscopic stone extraction was needed only in one patient (NPV 0.97). CONCLUSIONS: Pre-operative endosonography can spare unnecessary pre-operative endoscopic retrograde cholangiography as well as inappropriate scheduling of intra-operative endoscopic retrograde cholangiography in patients undergoing laparoscopic cholecystectomy with abnormal liver function tests. To maximise the impact of endosonography on the management of these patients, the procedure should be performed immediately before laparoscopic cholecystectomy.     

Management of unsuspected common bile duct stones found during laparoscopic cholecystectomy by means of transcystic catheter placement and papillary dilation

BACKGROUND: The optimal treatment strategy for treatment of bile duct stones first diagnosed during laparoscopic cholecystectomy has not been established. We prospectively treated unsuspected bile duct stones by means of intraoperative placement of a transcystic catheter followed by postoperative pharmacologic papillary dilation or endoscopic papillary balloon dilation. METHODS: In 17 patients with bile duct stones first found at laparoscopic cholecystectomy, a catheter was introduced via the cystic duct into the bile duct. If postoperative cholangiography via a transcystic catheter showed stones 5 mm or less in diameter, glyceryl trinitrate was infused via the catheter into the bile duct. Patients in whom medical dilation was unsuccessful or who had larger stones underwent endoscopic papillary balloon dilation. RESULTS: Stone diameter measured 3 to 11 mm (mean 6.4 mm). Postoperative cholangiography revealed spontaneous passage in four patients. After pharmacologic papillary dilation, two of five patients with stones 5 mm or less in diameter had stone clearance. The remaining 11 patients underwent successful endoscopic papillary balloon dilation with stone clearance. In two patients, a guidewire introduced via a transcystic catheter through the papilla facilitated selective biliary cannulation. One early minor complication occurred. All patients remained without symptoms for a mean follow-up of 13 months. CONCLUSION: For unsuspected bile duct stones (usually small ones), this strategy is a simple and effective alternative to laparoscopic bile duct exploration and postoperative sphincterotomy and may minimize early and late complications. Transcystic catheterization ensures access to the bile duct, thereby avoiding endoscopic treatment failures.     

La lithiase de la voie biliaire principale: sphinctérotomie endoscopique-précholécystectomie laparoscopique versus chirurgie ouverte

Objective

The aim of this prospective study was to show the place of preoperative endoscopic sphincterotomy in the treatment of common bile duct stones as an alternative to open surgery in developing countries.

Patients and methods

This study was done on 36 patients with common bile duct stones treated between January 2006 and December 2008, divided into two groups. Group 1 of 14 patients underwent first an endoscopic sphincterotomy followed by laparoscopic cholecystectomy, whereas group 2 of 22 patients was treated surgically.

Results

The analysis of clinical and biological signs did not show a significant difference between the two groups. Ultrasonography was used to make the diagnosis in 19.5% of the cases, the scanner in 41.6% of the cases, and the MRI in 38.9% of the cases. The morbidity and failure of group 1 were slightly lower compared to group 2 (14.3 vs 22.7% and 14.3 vs 18.2%). The average length of hospitalization was almost similar (6.7 vs 7.2 days). Only one death was noted in response to a serious acute cholangitis surgically treated.

Conclusion

The association of endoscopic sphincterotomy-laparoscopic cholecystectomy may be a good alternative to open surgery in the treatment of common bile duct stones in developing countries where the treatment of “anything” laparoscopic still requires improvement in the surgeons’ expertise and of the necessary equipment.