Laparoendoscopic approaches to common bile duct stones

Since the advent of laparoscopic cholecystectomy, there has been a debate regarding the most effective approach to intraoperative management of choledocholithiasis. Although transcystic duct extraction has been effective, the integration of flexible endoscopic methodology into the laparoscopic procedure has facilitated management of difficult cases. Variations of endoscopic retrograde cholangiopancreatography may be used during laparoscopic cholecystectomy or facilitated after the surgery by maneuvers at the time of operation. These techniques have been extremely effective in facilitating the laparoscopic treatment of common bile duct stones.     

Laparoscopic treatment of common bile duct stones

Whether for a diagnostic evaluation or for the treatment of common bile duct lithiasis, the laparoscopic approach is the most efficient method compared with the other alternatives. The authors describe in the present article the method to treat laparoscopically common bile duct lithiasis.     

Laparoscopic approach as primary treatment of common bile duct stones in children

Background

Preoperative endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy (ES) are an effective strategy for choledocholithiasis, but complications such as pancreatitis and outcome in children are unknown. The laparoscopic cholecystectomy became the new gold standard in children for cholelithiasis. For the choledocholithiasis in children, the attitude is more controversial. We analyzed our series of laparoscopic approach for the management of choledocholithiasis in children to determine if it is an effective procedure.

Patients and Method

Between 1996 and 2001, 126 children were treated for cholelithiasis in our institution; 13 children (10.3%) were managed for a choledocholithiasis. We reviewed age at symptom onset results of paraclinical examinations, the type of laparoscopic management, and postoperative outcome.

Results

The mean age at clinical signs was 9.9 years (range, 3 months-15.5 years). One child was excluded because he had a preoperative ES. Twelve children had a laparoscopic cholecystectomy and cholangiogram at the same time. A choledocholithiasis was found in 10 cases. A flush of the common bile duct (CBD) was performed in all cases with a 3F or 5F ureteral catheter; the stone was pushed into the duodenum in 3 cases and successfully extracted in 3 with a 4F Dormia or Fogarty catheter. One child needed a conversion to open surgery. Three times, an ES was necessary in postoperative course in each case for clinical and biologic signs of CBD obstruction or pancreatitis (30%). All children are symptom-free with an average follow-up of 28 months.

Conclusion

Laparoscopic CBD exploration for choledocholithiasis can be performed safely in children at the time of cholecystectomy and can clear all of the stones in the CBD in two thirds of cases. If there is residual obstruction, a postoperative ES can be performed. We suggest primary treatment of choledocholithiasis by laparoscopic approach in children.     

Laparoscopic treatment of common bile duct stones.

Common bile duct stones were present in sixteen of our first two hundred cases of laparoscopic cholecystectomy. Treatment included flushing into the duodenum, catheter drainage of the duct for cholangiographic and percutaneous access, open choledochotomy with stone removal and E.R.C.P., or combinations thereof. A technique for open choledocholithotomy with suture closure of the duct is presented.     

Primary common bile duct stones

Primary or stasis stones in the common duct are a distinct clinical, anatomical, and pathological entity. In the older patient with chills, fever, and jaundice, it is axiomatic that a primary or stasis stone will be found in a common duct that measures 20 mm or more in diameter. Furthermore, about 20% of such patients will not have stones in the gallbladder. The symptom of chills, having not been observed in patients with cancer of the head of the pancreas, is considered a diagnostic aid in the differentiation of jaundice secondary to common duct stones from jaundice due to malignant obstruction. The primary or stasis stone is the most common type of common duct stone. When present, a definitive operation, preferably choledochoduodenostomy, is advised. A simplified classification of biliary tract stones, preferably that of Aschoff, should be established as the universal standard. Also, based on this standard, worldwide prospective clinical studies should be initiated to obtain data for comparative evaluations to determine the true incidence of primary common duct stones.

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Résumé Les calculs cholédociens primaires ou de stase constituent une entité clinique, anatomique et pathologique. Chez le patient âgé avec frissons, fièvre et ictère, il faut s'attendre à trouver dans le cholédoque un calcul primaire ou de stase de 20 mm de diamètre ou plus, et 20% de ces malades n'ont pas de calculs vésiculaires. L'absence de frissons dans les ictères par cancer de la tête du pancréas est un élément de diagnostic différentiel des ictères obstructifs par lithiase ou cancer. Le calcul primaire ou de stase est le type le plus fréquent de calcul cholédocien. Lorsqu'il existe, il faut conseiller une opération curative, de préférence une cholédocoduodénostomie. Il serait souhaitable d'adopter partout une classification simple, mais non équivoque, des calculs biliaires, de préférence celle d'Aschoff. Une telle classification permettrait des études cliniques prospectives à l'échelle internationale, qui préciseraient la fréquence réelle des calculs cholédociens primaires.

     

Impacted common bile duct stones

The impacted common bile duct stone can be managed either surgically or radiologically using methods such as percutaneous basket extraction or endoscopic papillotomy. At operation, if an impacted common bile duct stone cannot be removed by the usual methods, duodenotomy and sphincteroplasty are indicated. If the patient's condition is good, sphincteroplasty should not be avoided in the belief that other means of stone removal are superior. However, if the patient's condition is not ideal, sphincteroplasty should be deferred in favor of delayed removal by percutaneous or endoscopic techniques. In patients without percutaneous access to the biliary tree, endoscopic papillotomy can be effective in removing impacted stones, or at least in relieving the obstruction and allowing improvement in the patient's condition before surgical intervention is attempted.     

经胆囊管途径治疗胆总管结石的可行性研究

目的:探讨腹腔镜经胆囊管途径治疗胆囊结石合并胆总管结石的可行性与安全性。方法:回顾分析2015年1月至2017年1月152例胆囊结石合并胆总管结石患者的临床资料,其中66例经胆囊管行腹腔镜胆总管探查术(laparoscopic transcystic common bile duct exploration,LTCBDE),为LTCBDE组;86例经胆总管行腹腔镜胆总管探查术(laparoscopic common bile duct exploration,LCBDE),为LCBDE组。统计分析两组患者一般情况、手术时间、术中出血量、腹腔引流时间、住院时间、住院总费用、并发症等指标。结果:两组均无中转开腹及死亡病例,手术时间差异无统计学意义(P0.05),LTCBDE组术后住院时间、术后腹腔引流时间、住院费用、术后胆漏发生率优于LCBDE组(P0.05)。LCBDE组中13例患者行T管引流,LTCBDE组均行胆总管一期缝合,差异有统计学意义(P0.05)。结论:LTCBDE可避免术后T管引流,缩短了住院时间,术后并发症少,具有安全、经济、有效的微创优势。     

不留置T管引流治疗胆囊结石并胆总管结石的临床疗效

目的:探讨不留置T管引流治疗胆囊结石合并胆总管结石的临床疗效。方法:回顾性分析2013年9月—2014年9月收治的100例胆囊结石合并胆总管结石患者的临床资料,其中45例行腹腔镜胆囊切除(LC)+胆总管探查胆道一期缝合术(一期缝合术组),55例行LC+经内镜下十二指肠乳头括约肌切开术(括约肌切开术组);所有患者随访12~24个月。对比分析两组患者的相关临床资料。结果:两组术前年龄、性别、胆红素、转氨酶及胆管结石直径差异均无统计学意义(均P0.05),但一期缝合术组胆总管扩张直径明显大于括约肌切开术组(P0.05)。100例均顺利完成手术、术后痊愈出院。两组患者术后第1天均可下床活动,手术时间、总住院时间、结石残余情况差异均无统计学意义(均P0.05);但一期缝合术组术中出血量、术后禁食水时间、术后住院时间、住院费用均少于括约肌切开术组(均P0.05);并发症方面,一期缝合术组术后胆汁漏5例,括约肌切开术组术后急性胰腺炎6例,差异有统计学意义(均P0.05)。结论:不留置T管引流的腹腔镜胆总管探查胆道一期缝合术,可保留Oddi括约肌功能、避免长期留置T管,更显微创技术优势,是一种有效、可行的术式,值得临床应用。     

微创治疗胆总管结石的术式选择

目的探讨不同条件下胆总管结石(CBDS)的微创手术方案。方法分析近9年间我科治疗的203例CBDS患者的临床资料。据手术方式不同分组:十二指肠镜下乳头气囊扩张取石术(EPBD)组(22例)、十二指肠镜下乳头括约肌切开取石术(EST)组(105例)、腹腔镜胆总管切开取石术(LCBDE)组(76例)。结果 3组的手术成功率、近期并发症发生率、残石率比较差异无统计学意义(P0.05)。手术时间3组比较差异有统计学意义(P=0.000),LCBDE组最短;住院时间3组间差异有统计学意义(P=0.000),EPBD组最短。随访期间结石复发率、反流性胆管炎及乳头狭窄发生率3组间差异有统计学意义(P0.05),LCBDE组与EPBD组相当,EST组最差。结论有适应证的CBDS患者首选EPBD,失败或无适应证者选择LCBDE,EST仅适用于有严格适应证者。     

Management of common bile duct stones

Conclusions Choledocholithiasis remains a complicated and challenging disease process for today’s clinicians. Transabdominal ultrasound and ERC are the most common preoperative imaging modalities with endoscopic ultrasound, MRCP, and HCT emerging as potentially more accurate and less invasive tools. Intraoperatively, LUS and IOC are complimentary in detecting CBD stones, while laparoscopic CBDE is commonly and safely performed by surgeons comfortable with advanced laparoscopic techniques. Postoperative ERC is effective with failure of laparoscopic CBDE, surgeon inexperience, and unfavorable anatomy and patient selection. Open CBDE should never be looked upon as a failure, while sphincterotomy, sphincteroplasty, and choledochoenterostomy remain necessary operations for certain patients. The proposed algorithm is only a guideline, and ultimate treatment depends on physician experience and available resources.     

Management of common bile duct stones

Background: Common bile duct stones are still a frequent problem. Although new diagnostic and therapeutic techniques are continually being development, they remain poorly defined. Therefore, we decided to evaluate our standard method of diagnosing and treating common bile duct stones. The aim of the study was to determine the short- and long-term results of this method. Methods: Between 1985 and 1995, 552 consecutive patients (200 men and 352 women; median age, 69 years) underwent endoscopic retrograde cholangiography (ERC) because of suspected common bile duct stones. If stones were detected, they were treated endoscopically, if possible. The results and complications of this policy were recorded. Patients were followed 1–13 years after undergoing ERC and endoscopic sphincterotomy (ES). Long-term results and complications during this period were also recorded. Results: ERC was attempted in 552 patients and succeeded in 510 patients (92%): ES was attempted in 315 patients and failed in five (98%). Duct clearance was done in 271 patients; in 26 of these patients, symptoms disappeared spontaneously. Ten patients underwent common bile duct exploration. Complications occurred in 46 patients (8.3%). Mortality was 0.4%, hemorrhage occurred in 3.6%, pancreatitis in 1.4%, sepsis and cholangitis also in 1.4%, and the lithotripter basket became impacted in four patients (0.8%), necessitating to common bile duct exploration. During follow-up, 45 patients (8%) returned, 35 with recurrent stones, five with cholangitis, two with stenosis of the papilla of Vater, and one with biliary pancreatitis. In 35 cases, complications were treated endoscopically, common bile duct exploration was performed in five cases, and symptoms disappeared spontaneously in five cases. Conclusions: ERC is a safe and reliable way of diagnosing common bile duct stones, and ES is a very efficient way of treating them. Morbidity and mortality are low, and the long-term results are very good.     

Laparoscopic common bile duct exploration and holmium laser lithotripsy: a novel approach to the management of common bile duct stones

Background  

Endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic common bile duct exploration (LCBDE) have proved to be safe and effective ways of managing common bile duct (CBD) stones. Clearance of large or impacted CBD stones by routine endoscopic maneuvers can be challenging, often requiring more invasive techniques such as open CBD exploration, which increases morbidity. This report presents a novel approach to managing impacted CBD stones using laparoscopic transcystic common bile duct exploration and holmium laser lithotripsy with favorable outcomes.     

腹腔镜联合胆总管探查术治疗胆囊并胆总管结石

目的探讨腹腔镜下胆囊切除联合胆总管探查取石一期缝合术治疗胆囊结石合并胆总管结石的疗效和安全性。方法回顾性分析2010年2月至2014年12月收治的74例胆囊结石合并胆总管结石患者的临床资料,分别采用腹腔镜下胆囊切除联合胆总管探查取石一期缝合术(观察组37例)和腹腔镜下胆囊切除,胆总管切开取石T管引流术(对照组37例),数据采用SPSS19.0软件处理,术后胃肠道功能恢复情况、电解质和肝肾功能比较以均数±标准差表示,采用t检验;术后并发症发生率采用χ~2检验,P0.05为差异有统计学意义。结果观察组并发症发生率为2.7%低于对照组为8.1%,差异有统计学意义(χ~2=9.83,P0.05);观察组血清Na+,K+水平分别为(145.8±3.2)mmol/L和(4.8±0.5)mmol/L,均高于对照组,其差异均有统计学意义(P0.05);观察组患者的首次排气时间为(1.2±0.4)d,肠鸣音恢复时间为(1.3±0.4)d,对照组患者的首次排气时间为(2.2±0.8)d,肠鸣音恢复时间为(1.8±0.5)d,差异均有统计学意义(t=2.81、2.89,P=0.010、0.006)。结论腔镜下胆囊切除联合胆总管探查取石一期缝合术可干净彻底地清除结石,同时降低术后胆漏、电解质紊乱,消化功能不良等并发症,具有较好的临床疗效和安全性。     

Sequential treatment of the common bile duct stones and cholecystolithiasis

The orthodox method of the treatment of gallstone disease is laparoscopic cholecystectomy (LC) days or weeks after endoscopic retrograde cholangiopancreatography + endoscopic spincterotomy (ERCP+ES). It can be advantageous from the point of financing, that is double reimbursement (2 x DRG). On the other hand there are some disadvantages of this procedure: longer hospital stay, further suffering of the patient, difficulties at operation because of inflammation provoked by ERCP (11% 14/120 in 3 month). We report on our experience with the treatment of common bile duct stones within 24 h by sequential endoscopic-laparoscopic management. The gallstone disease of a 32 year old woman was diagnosed by ultrasonography and laboratory tests. She had ERCP+ES in the morning and LC 7 hours later. There was no complication and the patient was discharged already on the 3rd day.     

ERCP与腹腔镜胆总管探查治疗胆囊结石合并胆总管结石的比较

目的比较ERCP与腹腔镜胆总管探查(LCBDE)治疗胆囊结石合并胆总管结石的优、缺点。 方法回顾分析2010年4月至2015年4月5年间诊治的197例胆囊结石合并胆总管结石患者。 结果ERCP组(99例)中有6例患者手术失败,32例合并胰腺炎,1例出现十二指肠壁穿孔。3例患者术后出现胆总管结石复发。LCBDE组(98例)中无手术失败,8例放置T管,无胆总管结石复发,无严重并发症。LCBDE组术后平均住院时间和平均住院费用均低于ERCP组[(5±2) d vs (3±1)d, (2.23±0.85)万元 vs (1.73±0.43)万元]。 结论ERCP＋EST和LCBDE对于胆囊结石合并胆总管结石都是行之有效的处理方法,对于大多数患者应首选LCBDE,对于特殊患者可选择ERCP＋EST＋LC方案。     

胆总管结石的诊疗进展

随着诊疗设备和技术的不断更新和发展,目前胆总管结石的诊疗方向沿着更加安全性、微创性、高效性的理念发展.本文通过查阅并总结相关文献,就胆总管结石诊疗方法方面的新进展做一综述.     

Laparoscopic management of common bile duct stones

Background While laparoscopic cholecystectomy is widely accepted for therapy of cholecystolithiasis, controversy still exists concerning the management of common bile duct stones. Besides preoperative endoscopic papillotomy followed by laparoscopic cholecystectomy and open common bile duct surgery, management of common bile duct stones can be conducted by laparoscopy, if respective experience is available.Method During laparoscopic cholecystectomy a cholangiography via the cystic duct is routinely performed. If bile duct stones are detected they are retrieved via the cystic duct or via incision of the common bile duct by insertion of a Fogarty catheter or Dormia basket. Exclusion criteria against simultaneous laparoscopic management include suspicion of malignancy, severe pancreatitis, or cholangitis.Results From November 1991 to March 2002, 200 patients primarily underwent laparoscopic therapy of bile duct stones. Retrieval was performed via cystic duct and common bile duct incision in 115 and 85 cases, respectively. Complete removal was achieved in 91%; complication rate and mortality was 7% and 0.5%, respectively. During the same period primary endoscopic papillotomy was necessary in 40 patients because of the above contraindications.Conclusions When correct indications and surgical expertise are observed, simultaneous laparoscopic management of common bile duct stones represents a safe and minimally invasive alternative to a two-procedure approach.