Choledocholithiasis

The best predictors for the presence of common bile duct stones (CBDS) are cholangitis, jaundice, and direct visualization of stones with ultrasound. In the setting of high suspicion of choledocholithiasis, endoscopic retrograde cholangiography (ERC) is indicated because when CBDS are identified, it allows immediate therapy in the same sitting. If there is a moderate probability of choledocholithiasis, endosonography or magnetic resonance cholangiopancreatography are the first-line options. In patients with gallbladder stones and CBDS, preoperative ERC with or without endoscopic sphincterotomy (ES) is widely recommended as a standard approach. The interval between that and laparoscopic cholecystectomy (LC) should be at least 24 h (<6 weeks) to exclude possible complications due to the ERC/ES. In the setting of open cholecystectomy, open bile duct surgery is significantly superior to ERC with sphincterotomy in achieving common bile duct clearance and is the method of choice. Only in centres with advanced laparoscopic expertise is the laparoscopic removal of CBDS an equivalent treatment option.     

Gallstone cholangitis: a 10-year experience of combined endoscopic and laparoscopic treatment

BACKGROUND: To date, no procedure has yet been identified as the gold standard for the treatment of gallstone cholangitis in the laparoscopic era. METHODS: The data of 109 consecutive patients with acute cholangitis were prospectively entered into a computerized database. All patients were managed according to a standard protocol. The main treatments were endoscopic retrograde cholangiography (ERC) combined with endoscopic sphincterotomy (ES), followed by interval laparoscopic cholecystectomy (LC). Patients in whom ERC or endoscopic stone clearance failed were managed by emergency open common bile duct exploration. LC was performed with a standardized four-cannula technique. The mean duration of surgery, conversion rate, and postoperative outcome of these patients were evaluated. RESULTS: ERC was successful in 103 patients (94.5%). In five of these patients (4.8%), no bile duct stones were found. The 98 patients (95.2%) with common bile duct stones were referred for ES. The bile duct stones were successfully removed after ES in 93 cases (94.9%). The overall failure rate of ERC and ES for choledocholithiasis was 10.1%. Self-limiting pancreatitis occurred in four patients (4.3%). Overall, two of the 109 patients died (1.8%). After ES, 81 patients underwent LC. LC was performed successfully in 74 patients (91.3%). Conversion to open surgery was required in seven patients (8.7%). The morbidity rate after cholecystectomy was 7.4%; the morbidity rate after open bile duct exploration was 36.4% (p<0.05). Fifteen patients were managed conservatively after initial endoscopic management of their cholangitis. The overall incidence of recurrent biliary symptoms was significantly higher among patients with gallbladder in place than for patients who underwent cholecystectomy (38.5% vs 1.5%, p<0.001). CONCLUSIONS: ES followed by LC is a safe and effective approach for the management of gallstone cholangitis; cholecystectomy should be performed in patients with gallstone cholangitis unless the operative risk is extremely high. These high operative risk patients and those who refuse surgery after ES should be warned that they are at high risk for recurrent biliary symptoms.     

Laparoscopic cholecystectomy and common bile duct stones. The utility of planned perioperative endoscopic retrograde cholangiography and sphincterotomy: experience with 63 patients.

OBJECTIVE: Planned perioperative endoscopic retrograde cholangiography (ERC) and sphincterotomy (ES) for suspected or proven common bile duct stones (CBDS) has been attempted in 63 of 540 consecutive patients undergoing laparoscopic cholecystectomy (LC). Experience with this intervention has been studied with respect to accuracy, efficacy, and safety. SUMMARY BACKGROUND DATA: The optimal management of CBDSs in the era of LC is not defined. Methods exist for the laparoscopic manipulation of the common bile duct; however, experience is limited. Until surgeons become comfortable with this more demanding technique, ERC and ES will have a prominent role in the perioperative management of CBDSs. METHODS: A preoperative group (n = 41) included all candidates for LC with historical, biochemical, or radiologic evidence of CBDSs. A postoperative LC group (n = 22) included patients with stones diagnosed by intraoperative cholangiogram (IOC) (n = 6) or with signs or symptoms of retained, but unproven, CBDSs (n = 16). RESULTS: Thirty-six (88%) of the preoperative attempts were successful. Stones were identified in 18 cases and ES and duct clearance were achieved in all 18. In the postoperative group, ERC was successful in 21 (95%) cases. Calculi were demonstrated in 5 of 6 patients with a positive IOC and 6 of 16 with clinically suspected retained stones. ES and duct clearance were achieved in all 11 patients with documented CBDSs. Overall, ERC was accomplished in 90% of cases. Stones were identified in 51% of cases and all stones were cleared by ES. Morbidity was confined to four cases of self-limited pancreatitis (6%). There were no deaths. CONCLUSIONS: The perioperative management of CBDSs is an appealing approach for patients anticipating the benefits of LC, at least until the laparoscopic manipulation of the common bile duct becomes a more widely accepted technique.     

Management of common bile duct stones in a single operation combining laparoscopic cholecystectomy and perioperative endoscopic sphincterotomy

BACKGROUND: Laparoscopic cholecystectomy (LC) has become the reference treatment for biliary lithiasis, but the management strategy for common bile duct stones (CBDS) remains a subject of controversy in the absence of an established consensus. While conventional surgery remains the reference treatment for CBDS, minimally invasive techniques are becoming more and more popular. These methods consist of the extraction of the common bile duct stones either exclusively by laparoscopy or by sequential treatment with endoscopic sphincterotomy (ES) followed by LC. The aim of this study was to evaluate the treatment of CBDS in a one-stage operation by laparoscopic cholecystectomy (LC) and perioperative endoscopic sphincterotomy. PATIENTS AND METHODS: Between January 1994 and March 1998, 44 patients, 20 male and 24 female, (sex ratio 1.2) with a median age of 57 years (range 28-84 years) were treated for suspected or confirmed CBDS. The CBDS were uncomplicated in 39 cases (88%) and associated with a complication in 5 cases (12%), namely, cholangitis (2 cases) or acute pancreatitis (3 cases). The perioperative ES was performed immediately after the LC during the same operative time, with perioperative cholangiography being systematically performed (1 failure). In 6 cases, a transcystic drain was left in place (to ensure complete evacuation of the CBDS postoperatively) when there were more than three stones and/or when they were larger than 6 mm. The patient was positioned in the left lateral position in order to perform the ES. RESULTS: Mean operative time for LC was 60 min, range 40-90 min. The general anesthesia was prolonged by 40 min in order to perform an ES (range 30-60 min).The perioperative ES was unsuccessful in one case (2%), due to the impossibility of catheterizing the papilla, the preoperative MR cholangiogram being normal. Immediate clearance of the CBD was achieved in 95% of the cases (42 p). In 2 cases, residual stone was found in the sixth day after cholangiography and was spontaneously evacuated as shown by 21st-day control. There was no mortality or postoperative complications. The duration of the postoperative hospitalization was 4.6 days (range 3-6). CONCLUSIONS: We believe that LC combined with perioperative ES is a quick, reliable, and safe technique for the treatment of CBDS during a single operative procedure, although this approach is limited by the proximity and availability of an endoscopic team.     

Intraoperative cholangiography can be safely omitted during laparoscopic cholecystectomy: a prospective study of 413 consecutive patients.

BACKGROUND AND AIMS: The aim of the study was to show that laparoscopic cholecystectomy (LC) can be performed safely without intraoperative cholangiography (IOC). MATERIAL AND METHODS: We conducted a prospective study of 413 consecutive patients with symptomatic gallstone disease, who underwent LC. According to the preoperative clinical, laboratory and ultrasound criteria, 38 patients (9.2%) were selected for preoperative endoscopic retrograde cholangiography (ERC). All patients were followed postoperatively for symptoms and signs of common bile duct (CBD) stones. RESULTS: Preoperative ERC allowed to make a diagnosis of choledocholithiasis in 22 (58%) of the 38 selected patients. Stone clearance was achieved with endoscopic sphincterotomy (ES) in all cases. Three patients (7.9%) had an episode of mild self-limited pancreatitis after the procedure. Eight patients (1.9%) of 413 required conversion from LC to open cholecystectomy. There were no CBD injuries and no death cases. Of the postoperative complications, 1.5% were recorded during hospital stay. During the follow-up period, for at least 2 years after surgery, retained CBD stones were verified in 6 patients (1.5%); however, the supposed rate of residual stones was 2.4%. CONCLUSIONS: This study demonstrates that performance of selective preoperative ERC with ES when necessary, followed by LC, is an appropriate and safe approach to the treatment of patients with cholecystolithiasis and unsuspected choledocholithiasis. This approach allows to omit IOC and to perform LC safely without biliary duct injuries, ensuring low rate of retained CBD stones in the late follow-up period.     

腹腔镜胆囊切除术时胆囊管嵌顿结石的处理

目的　总结腹腔胆囊切除术 (LC)时处理胆囊管结石嵌顿的经验。　方法　 1997年 7月～ 2 0 0 1年 6月 ,5 8例胆囊管结石嵌顿。先行胆囊管切开取石而后术中胆道造影 ,如发现胆总管结石则联合内镜切石或中转开腹。　结果　 5 8例均取石成功。 5 1例行单纯LC。术中胆道造影示胆总管结石 7例 ,5例行LC术中联合内镜下括约肌切开取石 ,2例中转开腹行胆总管切开取石联合T管引流。无严重并发症发生。　结论　几乎所有胆囊管结石嵌顿都可用胆囊管切开取石的方法完成LC ,并结合术中胆道造影 ,如发现胆总管结石可联合内镜括约肌切开取石。     

腹腔镜胆囊切除术前选择性ERC的应用

目的　探索ERC LC对有症状胆囊结石和疑有胆管结石得治疗结果的选择性标准的研究。方法　回顾分析 2 0 0 1年 11月～ 2 0 0 3年 10月我科收治的胆石症患者中 2 0例先行ERC再行LC的情况。结果　本组病人ERC均获成功 ,ERCP EST ESE共取出结石 15例 ,B超等证实者 10例 ,胆总管直径 >8mm 12例 ,有黄疸史者 11例 ,肝功能异常者 11例 ,胰腺炎者 4例。ERC后平均 4 .6d行LC。随访 2月～ 2年未发现胆管残余结石。结论　严格掌握LC前行ERC适应症 ,对于减少不必要ERC率 ,避免LC后胆管残留结石都具有重要作用。     

Selective cholangiography in 600 patients undergoing cholecystectomy with 5-year follow-up for residual bile duct stones

BACKGROUND: The need for cholangiography to identify possible bile duct stones in all patients undergoing cholecystectomy is controversial. AIMS: To assess the results of a policy for selective pre-operative endoscopic retrograde cholangiography (ERC) in patients undergoing laparoscopic cholecystectomy and to determine the incidence of postoperative symptomatic bile duct stones. PATIENTS AND METHODS: Between 1993 and 1998, 600 patients underwent laparoscopic cholecystectomy under one consultant surgeon. Patients were selected for pre-operative or postoperative ERC based on symptoms, liver function tests and/or abnormalities on ultrasonography. A general practitioner questionnaire was used to assess follow-up of patients with postoperative stones. RESULTS: Of 600 patients, 107 (18%) with a median age of 57 years and male:female ratio of 1:2.1 were selected to undergo pre-operative ERC; of these, 41 patients (38%) had bile duct stones. Postoperative ERC was performed in 30 patients (5%) and stones were identified in seven (23.3%). Three patients (0.5%) had stones removed within 15 days of operation and four (0.7%) between 2.6 months and 1.8 years. Median follow-up was 5.0 years (range, 2.5-7.5 years). The overall incidence of bile duct stones was 48 cases (8%). The stone rate was 11% in males and 7.3% in females. Stones were successfully extracted at ERC in 43 patients (89.6%). CONCLUSIONS: A policy of selective pre-operative ERC is the most effective technique for identifying and removing bile duct stones and the incidence of symptomatic gallstones following laparoscopic cholecystectomy is very low. With an overall stone rate of 8%, routine peroperative cholangiography is unnecessary and, in a surgical unit providing an ERC service, laparoscopic exploration of the bile duct is not a technique required for the management of bile duct stones.     

Laparoscopic transcystic choledochoscopy

Preoperative prediction of common bile duct stones (CBDS) is imprecise. Cholangiography during laparoscopic cholecystectomy (LC) is the best method for detection of CBDS. Treatment of most stones detected at LC can be safely accomplished using transcystic choledochoscopy and stone extraction. This technique is applicable in nearly 90% of patients with CBD calculi. It may be preferable to endoscopic sphincterotomy (ES) in younger patients and is probably equivalent to ES in patients over 65 years of age.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Phoenix, Arizona, USA, 2 April 1993     

"Sequential" treatment: is it the best alternative in cholecysto-choledochal lithiasis?

Laparoscopic cholecystectomy has become the treatment of choice for patients with symptomatic cholelithiasis. About 10-20% of patients with gallbladder stones may also present associated common bile duct stones. The management of the latter remains controversial because many different surgical strategies are available: laparoscopic treatment (laparoscopic common bile duct exploration), sequential endoscopic and laparoscopic treatment (endoscopic retrograde cholangiopancreatography/endoscopic sphincterotomy [ERCP/ES] prior to laparoscopic cholecystectomy), inverted sequential endoscopic-laparoscopic treatment (laparoscopic cholecystectomy followed by ERCP/ES), and combined endoscopic-laparoscopic treatment (laparoscopic cholecystectomy with intraoperative ERCP/ES). The aim of this study was to evaluate the efficacy and safety of sequential endoscopic-laparoscopic treatment in patients with cholecystocholedocholithiasis. We retrospectively analyzed the clinical, biochemical and radiological features of 552 patients operated on for cholelithiasis from 1991 to 2001. Common bile duct stones were suspected on the basis of increased serum levels of bilirubin, GOT, GPT, GGT, alkaline phosphatase; presence of jaundice; history of pancreatitis or cholangitis; dilated common bile duct (diameter > 8 mm) or common bile duct stones at hepatobiliary ultrasonography; presence of common bile duct stones at MR-cholangiography or at i.v. cholangiography. In patients with suspected common bile duct stones, preoperative ERCP was performed; if common bile duct stones were confirmed, ES was performed. When common bile duct stones were not suspected preoperatively, laparoscopic cholecystectomy was performed directly. Overall morbidity, mortality and conversion rates in the two groups were evaluated. Of 552 patients admitted for cholelithiasis, 62 (11.3%) underwent preoperative ERCP for suspected common bile duct stones. In 41 patients (66.1%) common bile duct stones were identified and ES with common bile duct stone extraction was performed in 40 patients (clearance: 97.5%). The overall morbidity was 16% (10 cases of post-ERCP acute pancreatitis); no mortality occurred. The conversion rate during subsequent laparoscopic cholecystectomy was 4.8%. In the group of patients with no suspicion of common bile duct stones, the conversion rate was 4.9%. Sequential treatment cannot be considered the best approach for patients with cholecystocholedocholithiasis because of its morbidity rate and the high rate of negative preoperative ERCP findings. Combined endoscopic-laparoscopic treatment seems to present more advantages, especially in term of morbidity, hospital stay and patient compliance and may, in future, be considered the treatment of choice for patients with cholecystocholedocholithiasis.     

Sequential endo-laparoscopic treatment in patients with common bile calculi

BACKGROUND: Laparoscopic treatment of common bile duct (CBD) stones is gaining great acceptance worldwide, but actually it requires skills and technologies too expensive for a great part of general surgeons. So endoscopic removal of CBD stones before cholecystectomy is usually performed. Since 1991 in our department we started a policy of selective preoperative cholangiopancreatography (ERCP) in patients suspected for choledocholithiasis and waiting for laparoscopic cholecystectomy. METHODS: A retrospective study has been made on a population of 1100 patients who underwent elective laparoscopic cholecystectomy in the period between January 1991 and December 1997. They were 391 male and 719 female with a mean age of 52 years, 126 of whom (11.5%) were selected to have ERCP preoperatively because they had clinical, biochemical and ultrasound signs of the presence of common bile duct stones (CBDS). RESULTS: Successful cannulation of the CBD was achieved in 124 cases (98.4%), with failures due to ampullary diverticula. In 7 cases (5.5%) a precut was necessary to obtain cannulation. Sphincterotomy was performed in 113 patients (89.7%). In 93 patients (73.8%) stones were found (87 macrolithiasis and 6 microlithiasis); in 91 (97.8%) stones were removed in one (87) or two (4) endoscopic session. There were 2 major complications (one bleeding and one severe pancreatitis) due to ERCP or a sphincterotomy. Two patients developed symptoms from unsuspected common bile duct stones after LC and were removed endoscopically. No complications during LC were due to ERCP or ES. CONCLUSIONS: Selective preoperative ERCP is an effective way of clearing the CBD stones before laparoscopic cholecystectomy, with low rate of complications related to endoscopic and laparoscopic procedures, and short mean hospital stay (5.5 days), according to the concept of minimally invasive treatment.     

Selective cholangiography. Current role in laparoscopic cholecystectomy.

The initial 22-month experience with laparoscopic cholecystectomy in 400 patients employing an algorithm of selective cholangiographic evaluation is reported. Preoperative or postoperative endoscopic retrograde cholangiography was performed whenever stones were suspected clinically. Preoperative endoscopic retrograde cholangiography was performed in 44 patients (11%), in whom 14 (3.5%) had an endoscopic sphincterotomy with extraction of common bile duct stones. Intraoperative cholangiography was performed in only eight patients (2%) almost exclusively to acquire experience with the technique, and all cholangiograms were normal. Laparoscopic cholecystectomy was successfully completed in 96% of the patients. There were no deaths in this series, and major complications occurred in only 5% of patients. Two patients (0.5%) had a significant common bile duct injury that was recognized and successfully repaired at the initial operation. No late common bile duct strictures have been recognized. Six patients (1.5%) underwent postoperative endoscopic retrograde cholangiography for suspected common bile duct stones, with three patients requiring endoscopic sphincterotomy and stone extraction. This experience suggests that the use of preoperative and postoperative endoscopic retrograde cholangiography can be based on clinical presentation and laboratory evaluation and does not need to be performed routinely. Routine intraoperative cholangiography is not necessary in most patients undergoing laparoscopic cholecystectomy. The authors conclude that laparoscopic cholecystectomy can be performed safely with the selective use of cholangiography.     

Endoscopic management of common bile duct stones leaving the gallbladder in situ. A cohort study with long-term follow-up

BACKGROUND: Obstructive jaundice caused by stones is a common disorder, mostly managed by endoscopic sphincterotomy followed by cholecystectomy. The aim of this study was to evaluate whether or not clearance of the common bile duct alone is sufficient as treatment for patients with choledocholithiasis. METHODS: A cohort with 447 patients with symptomatic cholecystocholedocholithiasis, undergoing endoscopic retrograde cholangiography (ERC) and if necessary sphincterotomy (ES). In 164 patients common bile duct stones were proven and treated endoscopically, without performing a subsequent cholecystectomy. All 164 patients were free of symptoms after the endoscopic intervention. This group of patients was compared with 78 patients who underwent cholecystectomy after endoscopic treatment of common bile duct stones. Patients were followed for 1-13 years after ERC and sphincterotomy results and complications were registered. RESULTS: The ages of the 164 patients in the in situ group were significantly higher than in the cholecystectomy group and the ASA classification (American Society of Anesthesiologists) was significantly higher in the in situ patients. Mean follow-up was 70.9 months. Of the in situ patients 27 (16%) returned with biliary symptoms; 12 with common bile duct stones, three with cholangitis, and one with stenosis of Vater's papilla. Eight patients returned with cholecystitis and 3 with symptomatic cholecystolithiasis. Thirteen patients underwent cholecystectomy and 11 were managed (also) endoscopically. Minor complications were 2 wound infections and 1 bleeding after cholecystectomy. Two patients (1%) died of abdominal sepsis due to cholecystitis. Of the patients who underwent cholecystectomy, 6 (7.6%) returned during follow-up. Three patients had common bile duct stones, 2 had cholangitis and 1 patient presented with papillostenosis. Three patients needed surgical common bile duct exploration and the other 3 were treated endoscopically. After reintervention, cardiopulmonary complications were observed in 1 patient. There was no related death. CONCLUSION: When common bile duct stones are treated successfully by endoscopic sphincterotomy and patients are free of symptoms, there is no need for routine prophylactic cholecystectomy.     

Scoring system to predict asymptomatic choledocholithiasis before laparoscopic cholecystectomy

Background: The purpose of this prospective study was to evaluate if a recently proposed score system based on six preoperative parameters [history of colic pain and/or jaundice, dyspepsia, cholecystitis, ultrasound (US), evidence of common bile duct stones (CBDS), number and size of gallbladder stones at US, level of serum glutamic oxalacetic transaminase and/or alkaline phosphatase is effective in the selection of patients undergoing laparoscopic cholecystectomy (LC) with asymptomatic CBDS and could allow a significant reduction of the total number of preoperative examinations. Methods: In the case group, 408 patients were categorized into low-, medium-, and high-risk classes and underwent, respectively, no further preoperative assessment of the bile duct, intravenous cholangiography (IVC), and endoscopic retrograde cholangiography (ERC). Intraoperative cholangiography (IOC) was performed whenever the surgeon was in doubt as to biliary anatomy or bile duct clearance. These patients were compared with 408 retrospectively matched patients (control group) undergoing routine preoperative IVC and/or ERC. Results: In the case group, significantly lower numbers of IVC (120 vs 392) and IOC (3 vs 16) were performed (p < 0.005), whereas no difference in the total number of ERCs was noted. One patient in the control group had retained CBDS detected during follow-up evaluation, whereas none occurred in the case group. Conclusion: The proposed scoring system allows selective use of IVC, ERC, and/or IOC in patients undergoing elective LC.     

十二指肠镜、腹腔镜序贯治疗胆石症2 248例分析

目的探讨十二指肠镜、腹腔镜序贯性诊治胆石症的价值. 方法回顾性分析2000年1月～2004年12月采用十二指肠镜、腹腔镜序贯性诊治方案治疗胆石症2 248例的临床资料. 结果确诊胆囊结石1 817例,胆囊结石合并胆总管结石431例.B超诊断为胆囊结石2 021例中,行术前ERCP 690例,发现胆总管结石213例;术中胆道造影(IOC)85例,发现胆总管结石10例;腹腔镜胆囊切除(LC)术后胆总管残余结石6例,并经EST治愈.B超诊断胆囊结石合并胆总管结石227例中,ERCP证实胆总管结石202例.行LC 1 817例,EST LC 395例,LBDE 36例(其中胆管一期缝合26例,T管引流10例).全组中转开腹28例(1.2%),并发症52例(2.3%). 结论十二指肠镜、腹腔镜序贯性诊治方案治疗胆石症,体现了内镜、腔镜联合应用的优势,术后残余结石率低,微创治疗成功率高.     

Can three-dimensional helical CT cholangiography before laparoscopic cholecystectomy be a substitute study for endoscopic retrograde cholangiography?

The study investigated the usefulness of three-dimensional helical computed tomography (3D-CT) before laparoscopic cholecystectomy (LSC) when compared with that of endoscopic retrograde cholangiography (ERC). Forty-five patients referred for LSC, who had undergone 3D-CT cholangiography and ERC simultaneously, participated in the study. Endoscopic retrograde cholangiography and 3D-CT cholangiography were compared in each patient with regard to opacification of the biliary tree, stones, and anatomic variations. Three-dimensional helical CT cholangiography and ERC imaging for predicting operative difficulties in LSC also were compared. The common bile duct and cystic duct were shown in the patients by the images, but the gallbladder was shown in 43 patients (96%) with use of 3D-CT cholangiography and in 36 patients (80%) with use of ERC. A third or more peripheral branches were shown completely with use of 3D-CT cholangiography in 33 patients (73%) and in 32 patients (71%) with use of ERC. Cystic duct stones were found in two of three patients with use of 3D-CT cholangiography and ERC. Common bile duct stones in five of seven patients were detected with use of 3D-CT cholangiography, but all of the common bile duct stones were detected with use of ERC. Anatomic variations of the bile duct were shown in three of four patients by 3D-CT cholangiography and in all patients with use of ERC. No significant differences in findings of the angle of bifurcation and presence of Heister valves between operative easy and complex cases were shown by 3D-CT cholangiography and ERC, despite the more accurate assessment of the cystic duct anatomy with use of 3D-CT cholangiography than with use of ERC. Three-dimensional helical CT cholangiography is useful clinically in preoperative assessment of biliary anatomy, but it is not reliable in the detection of common bile duct stones, and it is not helpful in predicting technical difficulty during LSC.     

Sequential intraluminal endoscopic and laparoscopic treatment for bile duct stones associated with gallstones

Background: On the basis of a flowchart including prior or current jaundice or pancreatitis, abnormal liver function, ultrasound or IV cholangiography, bile duct (BD) stones were suspected in 71/593 patients referred for gallstones. Methods: When endoscopic retrograde cholangiography detected BD stones, endoscopic sphincterotomy (ES) and endoscopic BD clearance were attempted, followed by laparoscopic cholecystectomy (LC). BD stones were found in 44/71 patients. The sensitivity values of preoperative conditions were: 92% for IV cholangiography, 88% for abnormal liver function, 50% for ultrasound, and 37% for jaundice at admission. Results: Endoscopic clearance succeeded in 37 patients and LC was completed in 33 patients. Conversion to open surgery (9%) was comparable with the rate in patients without BD stones. The median hospital stay for the sequential endoscopic and laparoscopic treatments was 13 days (range 4–54) or 22 days if open surgery was used. Conclusions: In conclusion, BD stones can be endoscopically cleared preoperatively in most patients without interfering with LC.     

Endoscopic sphincterotomy prior to laparoscopic cholecystectomy for the treatment of cholelithiasis

BACKGROUND: We performed this study to assess the outcome of endoscopic retrograde cholangiography (ERC) before laparoscopic cholecystectomy (LC) for symptomatic gallbladder and suspected duct stones. METHODS: We performed prospective study of 310 patients with symptomatic gallstones and suspected choledocholithiasis managed by preoperative ERC with endoscopic extraction (ESE) and LC. The presence of one or more of the following criteria at hospital admission led to preoperative ERC because of suspected choledocholithiasis: jaundice for more than 72 h, ultrasonography measurement of the common bile duct > 8 mm, cholestasis, and acute biliary pancreatitis. RESULTS: ERC for suspected choledocholithiasis was performed in 310 patients. The rate of successful cannulation for ERC was 96.8%. Duct stones were found in 86%. Twelve patients had impacted duct stones cleared at open common duct exploration. The failure rate of ERC was 4.5%, and the rate of unnecessary ERC was 13.5%. LC was performed in 298 of 310 patients. Morbidity rates were 2.2% and 1.5% after ESE and LC, respectively. CONCLUSION: A total of 95.5% of patients with symptomatic gallbladder and ductal stones could be successfully managed by ERC prior to LC with a low morbidity rate.     

Evaluation of laparoscopic treatment of common bile duct stones in a prospective series of 505 patients: indications and results

BACKGROUND: The aim of this prospective study was the evaluation of the laparoscopic treatment of common bile duct stones (CBDS) and its indications. METHODS: Five hundred five patients who underwent laparoscopic treatment of CBDS from October 1990 to September 2006 were included in the prospective study. The mean age of the patients was 63 years (range = 19-93). Four hundred fifteen patients were classified ASA I and ASA II and 90 were ASA III and ASA IV. CBDS were suspected or diagnosed preoperatively in 373 patients (73.8%) and diagnosed at intraoperative cholangiography (IOC) in 132 patients (26.2%). A transcystic duct extraction (TCDE) was attempted in 254 patients (50.4%) and a primary choledochotomy in 251 patients (49.6%). Biliary drainage after choledochotomy was used in 148 cases (48.8%). RESULTS: TCDE was successful in 191 cases (75.2%).The 63 failures were managed by laparoscopic choledochotomy in 53 cases and by endoscopic sphincterotomy (ES) in 10 cases. A choledochotomy was thus performed in 304 patients and successful in 295 cases (97%). The nine failures were managed by six conversions to laparotomy (2%) and three postoperative ES. The overall success rate was 96.2%. The morbidity rate was 7.9% with 4.8% of local complications and 3.1% of general complications. The mortality rate was 1%. There were 14 residual stones (2.8%) that were managed by a second laparoscopy in two cases and by ES in 12 cases with four failures managed by laparotomy in one case and laparoscopy in three cases. CONCLUSION: Laparoscopic management of CBDS was effective in more than 96% of cases and particularly safe in ASA I and ASA II patients. It has the advantage over ES followed by laparoscopic cholecystectomy (LS) to be a one-stage procedure.