Cholecystectomy without operative cholangiography. Implications for common bile duct injury and retained common bile duct stones.

OBJECTIVE: This study evaluated the selective use of endoscopic retrograde cholangiopancreatography (ERCP) in the context of laparoscopic cholecystectomy (LC) while minimizing the use of operative cholangiography. SUMMARY BACKGROUND DATA: There has been a long-standing debate between routine and selective operative cholangiography that has resurfaced with LC. METHODS: Prospective data were collected on the first 1300 patients undergoing LC at McGill University. Preoperative indications for ERCP were recorded, radiologic findings were standardized, and technical points for a safe LC were emphasized. RESULTS: A total of 106 patients underwent 127 preoperative ERCPs. Fifty patients were found to have choledocholithiasis (3.8%), and clearance of the common bile duct (CBD) with endoscopic sphincterotomy was achieved in 45 patients. The other five patients underwent open cholecystectomy with common duct exploration. Intraoperative cholangiography (IOC) was attempted in only 54 patients (4.2%), 6 of whom demonstrated choledocholithiasis. Forty-nine postoperative ERCPs were performed in 33 patients and stones were detected in 17 (1.3%), with a median follow-up time of 22 months. Endoscopic duct clearance was successful in all of these. The incidence of CBD injury was 0.38%, and a policy of routine operative cholangiography might only have led to earlier recognition of duct injury in one case. The rate of complication for all ERCPs was 9% and the associated median duration of the hospital stay was 4 days. The median duration of the hospital stay after open CBD exploration was 13 days. CONCLUSIONS: LC can be performed safely without routine IOC. The selective use of preoperative and postoperative ERCP will clear the CBD of stones in 92.5% of patients.     

For patients with predicted low risk for choledocholithiasis undergoing laparoscopic cholecystectomy, selective intraoperative cholangiography and postoperative endoscopic retrograde cholangiopancreatography is an effective strategy to limit unnecessary procedures

Background  There is debate about whether intraoperative cholangiography (IOC) should be performed routinely or selectively during laparoscopic cholecystectomy (LC) in patients with suspected choledocholithiasis. The timing of endoscopic retrograde cholangiopancreatography (ERCP) in these patients also is an issue. We reviewed the experience in our center, where a management algorithm limiting ERCP in relation to LC was adopted. Methods  We retrospectively reviewed every LC performed by one surgeon during 6 years and the related ERCPs. Results  A total of 264 LCs were performed. In 30 patients, stones were cleared or excluded by preoperative ERCP. In the remaining 234 LCs, 31 of 34 IOCs were successfully performed. Two of 31 IOCs were positive for bile duct stones; stone removal was successful in each patient at subsequent ERCP. Only 10 of 201 patients who did not have IOC required postsurgical ERCP within 10 weeks of LC, 3 of whom had common bile duct stones at ERCP. Conclusions  For patients who underwent LC, we performed selective IOC with postoperative ERCP for positive studies. Review of our experience using this algorithm showed it to be a powerful tool in limiting unnecessary ERCPs. Our data suggest that routine preoperative ERCP cannot be justified. Selective IOC during LC misses relatively few cases of biliary stones; these can be managed quickly by experienced endoscopists.     

Current management of common bile duct stones in a teaching community hospital

The advent of laparoscopic cholecystectomy (LC) has complicated management of common bile duct (CBD) stones. While LC is routine, laparoscopic CBD exploration (LCBDE) is not, and an algorithm to manage suspected choledocholithiasis has not been uniformly accepted. We evaluated current management of choledocholithiasis. Patients suspected of having CBD stones over a 2-year period were evaluated, and 42 studies in the literature were reviewed. Thirty-two patients were identified. Fourteen patients (44%) had LC with intraoperative cholangiogram (IOC) with no preoperative studies. IOC revealed CBD stones in nine (64%). Seven had CBD exploration (CBDE) at cholecystectomy, and two had postoperative endoscopic retrograde cholangiopancreatography (ERCP). CBDE was successful in five cases, and ERCP was successful in one. Eighteen patients (56%) underwent preoperative ERCP. Five (28%) had no CBD stones. ERCP removed stones in nine patients, and four had open CBDE after failed ERCP. Current literature supports LC with IOC without any preoperative studies. Laparoscopic CBDE is highly successful but depends on surgeon experience. Removing CBD stones with ERCP is also very successful but is associated with increased cost, hospital stay, and complications. We conclude that LC with IOC should be performed without preoperative ERCP when choledocholithiasis is suspected. If found, stones should be removed laparoscopically if possible.     

Preoperative screening with ultrasonography for laparoscopic cholecystectomy: an alternative to routine intraoperative cholangiography.

BACKGROUND. Laparoscopic management of choledocholithiasis is not routinely successful. A prospective study was undertaken to determine if preoperative screening with ultrasonography and liver function tests (LFTs) could minimize the incidence of unsuspected choledocholithiasis. METHODS. One hundred twenty-one patients were studied. Patients with a common bile duct greater than 6 mm and either clinical symptoms or elevated LFT results were referred for preoperative endoscopic retrograde cholangiopancreatography (ERCP). RESULTS. Ten patients (8%) were referred for preoperative ERCP, of whom seven had choledocholithiasis, two had papillary stenosis, and one had a normal examination (90% positive ERCPs). One hundred eight patients underwent successful laparoscopic cholecystectomy. Nine patients underwent postoperative ERCP dictated by increasing common bile duct size, elevated enzyme levels, or symptoms. Four patients (3%) had choledocholithiasis that was successfully treated endoscopically. One patient had papillary stenosis, one had oriental cholangitis, and three had normal results on examination. CONCLUSIONS. In this study ultrasonography and LFTs identified patients at high risk for choledocholithiasis, allowing preoperative referral for endoscopic stone extraction.     

Changing Methods of Imaging the Common Bile Duct in the Laparoscopic Cholecystectomy Era in Western Australia: Implications for Surgical Practice

OBJECTIVE: To assess changes in the use of endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography (IOC), and surgical exploration of the common bile duct (CBD) associated with the introduction of laparoscopic cholecystectomy (LC). SUMMARY BACKGROUND DATA: The optimal strategy for dealing with potential stones of the CBD during LC remains controversial. METHODS: The authors conducted a population-based study of all cases of cholecystectomy (20,084) in Western Australia in the periods before, during, and after the introduction of LC (1988-1994). Index admissions were linked to previous or subsequent admissions for ERCP. Factors associated with ERCP were analyzed by multivariate regression models. RESULTS: Between 1988 and 1994, admissions for ERCP almost doubled, whereas the use of IOC decreased from 71% to 51%. Different trends were found for open and laparoscopic procedures. Exploration of the CBD declined because of the infrequent use of this procedure in LC. Preoperative ERCP was significantly more common in older patients and men; the reverse was found for IOC. There was an adjusted 3.5-fold increase in preoperative ERCP both during and after the introduction of LC. The adjusted odds ratios for IOC were 0.48 and 0.52 for these periods. CONCLUSIONS: The introduction of LC was associated with increasing reliance on ERCP to image the CBD and a decrease in the use of IOC. These changes were observed in both LC and open cholecystectomy. They suggest that the use of ERCP before cholecystectomy has partly replaced IOC for visualization of the CBD for suspected stones. Although more than 40% of patients undergoing LC had IOC, surgeons appear to be reluctant to perform surgical exploration of the CBD when stones are present. Savings in terms of both complications and cost can be expected if preoperative ERCPs performed for suspicion of uncomplicated CBD stones are replaced by IOC.     

Evaluation of perioperative cholangiography in one thousand laparoscopic cholecystectomies

We analyzed a teaching institution's experience with intra-operative cholangiography (IOCG) and endoscopic retrograde cholangiopancreatography (ERCP) and established an algorithm for their timing and use. The records of all patients undergoing LC during a five year period were reviewed. Patients with a history of jaundice or pancreatitis, abnormal bilirubin, alkaline phosphatase, serum glutamic-oxaloacetic transaminase, or radiographic evidence suggestive of choledocholithiasis were considered "at risk" for common bile duct stones (CBDS). The remaining patients were considered to be at low "risk." LC was attempted on 1002 patients during the study period and successfully completed on 941 (94% of the time). The major complication rate was 3.1% and the common bile duct injury rate 0.1%. Eighty eight (9.5%) patients underwent ERCP, 67 in the preoperative period and 19 in the postoperative period. IOCG was attempted in 272 (24%) patients and completed in 234 for a success rate of 86%. Intraoperative cholangiography (IOCG) and preoperative endoscopic retrograde cholangiopancreatography (ERCP) were equivalent in the detection of CBDSs Twelve of the 21 patients (57%) with IOCG positive for stones underwent successful laparoscopic clearance of the common duct, and did not require postop. ERCP. No patients were converted to an open procedure for common bile duct exploration. Because postoperative ERCP was 100% successful in clearing the common duct, reoperation for retained common bile duct stones was not necessary. IOCG is an alternative procedure to ERCP for patients at risk with biochemical, radiological, or clinical evidence of choledocholithiasis. The incidence of CBDS in low-risk patients is 1.7%, a risk that does not warrant routine cholangiography. Preoperative ERCP is recommended in cases of cholangitis unresponsive to antibiotics, suspicion of carcinoma, and biliary pancreatitis unresponsive to supportive care. Although IOCG leads to a similar percentage of nontherapeutic studies as preoperative ERCP, it often allows for one procedure therapy.     

Management of Preoperatively Suspected Choledocholithiasis: A Decision Analysis

Background  The management of symptomatic or incidentally discovered common bile duct (CBD) stones is still controversial. Of patients undergoing elective cholecystectomy for symptomatic cholelithiasis, 5–15% will also harbor CBD stones, and those with symptoms suggestive of choledocholithiasis will have an even higher incidence. Options for treatment include preoperative endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy (ERCP/ES) followed by laparoscopic cholecystectomy, laparoscopic cholecystectomy with intraoperative cholangiogram (LC/IOC), followed by either laparoscopic common bile duct exploration (LCBDE) or placement of a common bile duct double-lumen catheter with postoperative management. The purpose of this analysis was to determine the optimal management of such patients. Methods  A decision analysis was performed to analyze the management of patients with suspected common bile duct stones. The basic choice was between preoperative ERCP/ES followed by LC, LC/IOC followed by LCBDE, or common duct double-lumen catheter (Fitzgibbons tube) placement with either expectant management or postoperative ERCP/ES. Data on morbidity and mortality was obtained from the literature. Sensitivity analysis was done varying the incidence of positive CBD stones on IOC with associated morbidity and mortality. Results  One-stage management of symptomatic CBD stones with LC/LCBDE is associated with less morbidity and mortality (7% and 0.19%) than two-stage management utilizing preoperative ERCP/ES (13.5% and 0.5%). Sensitivity analysis shows that there is an increase in morbidity and mortality for LC/LCBDE as the incidence of positive IOC increases but are still less than two-stage management even with a 100% positive IOC (9.4%, 0.5%). If a double-lumen catheter is to be used for positive IOC, the morbidity would be higher than two-stage management only if the positive IOC incidence is more than 65% but still with no mortality. Conclusion  LCBDE has lower morbidity and mortality rates compared to preoperative ERCP/ES in the management of patients with suspected CBD stones even if the chance of CBD stones reaches 100%. Using a common duct double-lumen catheter may be considered if LCBDE is not feasible and the chance of CBD stone is less than 65%. Presented in part at the 49th Annual Meeting of the Society for Surgery of the Alimentary Tract [Poster Session], San Diego, CA, May 17–21, 2008     

Incidence of residual choledocholithiasis detected by intraoperative cholangiography at the time of laparoscopic cholecystectomy in patients having undergone preoperative ERCP

Introduction  The purpose of this study is to determine the incidence of residual common bile duct (CBD) stones after preoperative ERCP for choledocholithiasis and to evaluate the utility of routine intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) in this patient population. Methods  All patients who underwent preoperative ERCP and interval LC with IOC from 5/96 to 12/05 were reviewed under an Institutional Review Board (IRB)-approved protocol. Data collected included all radiologic imaging, laboratory values, clinical and pathologic diagnoses, and results of preoperative ERCP and LC with IOC. Standard statistical analyses were used with significance set at p < 0.05. Results  A total of 227 patients (male:female 72:155, mean age 51.9 years) underwent preoperative ERCP for suspicion of choledocholithiasis. One hundred and eighteen patients were found to have CBD stones on preoperative ERCP, and of these, 22 had choledocholithiasis diagnosed on IOC during LC. However, two patients had residual stones on completion cholangiogram after ERCP and were considered to have retained stones. Therefore, 20 patients overall were diagnosed with either interval passage of stones into the CBD or a false-negative preoperative ERCP. In the 109 patients without CBD stones on preoperative ERCP, nine patients had CBD stones on IOC during LC, an 8.3% incidence of interval passage of stones or false-negative preoperative ERCP. In both groups, there was no correlation (p > 0.05) between an increased incidence of CBD stones on IOC and a longer time interval between ERCP and LC, performance of sphincterotomy, incidence of cystic duct stones, or pathologic diagnosis of cholelithiasis. Conclusions  The overall incidence of retained or newly passed CBD stones on IOC during LC after a preoperative ERCP is 12.9%. Although the natural history of residual CBD stones after preoperative ERCP is not known, the routine use of IOC should be considered in patients with CBD stones on preoperative ERCP undergoing an interval LC.     

ERCP,cholangiography, and laparoscopic cholecystectomy

Summary With the increased use of laparoscopic cholecystectomy (LC), the roles of preoperative ERCP and intraoperative cholangiography (IOC) may be changing. SAGES members were surveyed to define opinions regarding use of ERCP and cholangiography during LC. Thirty-seven percent of the surveys were returned. Most respondents (83%) performed LC, reporting data on 19,747 LCs. Conversion to open cholecystectomy was required in 4% of cases. Complications were reported in 1.7% patients. IOC was attempted in 51.2% cases and was successful in 73%. Routine IOC was only recommended by approximately 50% of respondents. However, 80% recommended IOC for patients with multiple small gallstones and a dilated cystic duct. If preoperative liver function tests (LFTs) were mildly elevated (1.5×normal), only 56% of respondents recommended preoperative ERCP. However, 73% of respondents suggested preoperative ERCP for more severe LFT abnormalities. If preoperative ERCP demonstrated choledocholithiasis, most (85%) recommended endoscopic clearance of stones followed by LC. These opinions will be helpful in establishing practice standards for LC.Presented at The Society of American Gastrointestinal Endoscopic Surgeons Scientific Meeting, Washington, D.C., April 1992     

Cost-effective management of common bile duct stones

Background: There are a variety of approaches to the diagnosis and treatment of common bile duct (CBD) stones in patients undergoing laparoscopic cholecystectomy (LC). Methods: Decision modeling was used to evaluate the cost-effectiveness of four strategies for managing CBD stones around the time of LC: (a) routine preoperative endoscopic retrograde cholangiopancreatography (ERCP) (preoperative ERCP), (b) LC with intraoperative cholangiography (IOC), followed by laparoscopic common bile duct exploration (LCDE), (c) LC with IOC, followed by ERCP (postoperative ERCP), and (d) expectant management (LC without any tests for CBD stones). Local hospital data were used to estimate costs. Cost-effectiveness was expressed in terms of the cost per case of residual CBD stones prevented (in excess of the cost of LC alone). Diagnostic test characteristics, procedure success rates, and adverse event probabilities were derived from a systematic review of the literature. Sensitivity analysis was used to explore the effect of uncertainty on the results of the model. Results: LC alone was the least costly strategy, but it was also the least effective. Of the more aggressive strategies, LCDE and preoperative ERCP were associated with marginal costs of $5993.60 and $299,259.35, respectively, per case of residual CBD stones prevented. Postoperative ERCP was more costly and less effective than LCDE, but it had a lower cost-effectiveness ratio than preoperative ERCP when the prevalence of CBD stones was < 80%. CONCLUSIONS: COMPARED TO OTHER COMMON APPROACHES, LAPAROSCOPIC CBD EXPLORATION IS A COST-EFFECTIVE METHOD OF MANAGING CBD STONES IN PATIENTS WHO UNDERGO LC. IF EXPERTISE IN LCDE IS UNAVAILABLE, SELECTIVE POSTOPERATIVE ERCP IS PREFERRED OVER ROUTINE PREOPERATIVE ERCP, UNLESS THE PROBABILITY OF CBD STONES IS VERY HIGH (>80%).     

Preoperative versus postoperative endoscopic retrograde cholangiopancreatography in mild to moderate gallstone pancreatitis: a prospective randomized trial

OBJECTIVE: To determine whether endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct (CBD) stone extraction should be performed routinely before surgery or'selectively after surgery in patients with mild to moderate gallstone pancreatitis. SUMMARY BACKGROUND DATA: The role and timing of ERCP in mild to moderate gallstone pancreatitis remains controversial. Routine preoperative ERCP identifies persisting CBD stones but carries risks of complications and may delay definitive care. Selective postoperative ERCP, performed only if a CBD stone is seen on intraoperative cholangiography (IOC), avoids unnecessary ERCP but risks unsuccessful stone extraction. METHODS: A prospective, randomized study of consecutive patients with gallstone pancreatitis was conducted. Using previously determined criteria, patients with acute cholangitis or necrotizing pancreatitis were excluded. Patients considered at high risk for persisting CBD stones (CBD size > or =8 mm on admission ultrasound, serum total bilirubin > or = 1.7 mg/dL, or serum amylase > or = 150 U/L on hospital day 4) were randomly assigned to routine preoperative ERCP followed by laparoscopic cholecystectomy, or laparoscopic cholecystectomy with selective postoperative ERCP and endoscopic sphincterotomy only if a CBD stone was present on IOC. Primary end points were costs, length of hospital stay, and the combined treatment failure rates (failure of diagnostic ERCP and IOC, complications of ERCP and endoscopic sphincterotomy, and complications of surgery). RESULTS: One hundred fifty-four consecutive patients with gallstone pancreatitis were evaluated prospectively for study eligibility. Sixty patients met the randomization criteria. Thirty patients were randomized to routine preoperative ERCP and 29 patients to selective postoperative ERCP (1 patient refused). Age, admission laboratory values, and APACHE II and Imrie scores were similar in both groups. By protocol, ERCP was performed in all patients in the preoperative ERCP group. In the postoperative ERCP group, ERCP was necessary in only 7 of 29 patients (24%). Mean hospital stay was significantly longer in the routine preoperative ERCP group (11.7 days) than in the selective postoperative ERCP group (9.0 days). Mean total cost was higher in the preoperative ERCP group ($9,426) than in the postoperative ERCP group ($7,798). The combined treatment failure rate was 10% in both groups. CONCLUSIONS: In patients with mild to moderate gallstone pancreatitis without cholangitis, selective postoperative ERCP and CBD stone extraction is associated with a shorter hospital stay, less cost, no increase in combined treatment failure rate, and significant reduction in ERCP use compared with routine preoperative ERCP.     

ERCP in association with laparoscopic cholecystectomy

Background With the evolution of laparoscopic cholecystectomy (LC) as the standard operation for benign gallbladder disease, the role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of common bile duct (CBD) stones has to be defined. Methods From November 1990 to April 1994 we attempted LC in 1,788 patients. Eighty-nine patients underwent ERCP preoperatively under the following indications: jaundice or a history of jaundice, cholangitis, gallstone pancreatitis, abnormal liver function tests, and a sonogram showing either CBD stones or a dilated CBD. With intent to minimize the number of unnecessary ERCPs only patients with jaundice, cholangitis, and high abnormalities on the liver function tests (LFTs) were directly referred for ERCP. All other patients with suspected choledocholithiasis were initially investigated with intravenous cholangiography (IVC) and tomography; only patients with positive findings on IVC subsequently underwent ERCP. Eighteen patients underwent ERCP postoperatively and the indications included jaundice, bile leak, and abnormal intraoperative cholangiogram. Results Of the 89 patients having ERCP preoperatively 54 patients (60.7%) were found to have CBD stones which were removed endoscopically in all cases except in one patient where a large CBD stone was removed during laparoscopic exploration of the CBD. Eight patients of the 18 patients having ERCP postoperatively were found to have CBD stones and all of them had their CBD cleared endoscopically. There were no mortalities, while four patients developed a mild pancreatitis. Conclusions Although there is an increasing tendency to clear the bile duct with a laparoscopic approach, ERCP and sphincterotomy has a certain role in conjunction with LC in the management of patients with a high suspicion of CBD stones, particularly in institutions where there is easy access to expert interventional endoscopic techniques.     

Routine intraoperative cholangiography during laparoscopic cholecystectomy minimizes unnecessary endoscopic retrograde cholangiopancreatography in children

PURPOSE: The aim of this study was to determine the necessity for intraoperative cholangiography (IOC) during pediatric laparoscopic cholecystectomy (LC). METHODS: A retrospective review of 100 consecutive patients undergoing LC was conducted. RESULTS: Ninety-eight children underwent successful LC. The average age was 11.3 years. IOC was successful in 55 of 63 studies. Operating time for patients with IOC averaged 91 minutes, and without IOC, 67 minutes. Twenty children had preoperative ultrasound, laboratory, or clinical evidence of common bile duct (CBD) stones. Fifteen of these 20 children actually had CBD stones. Three additional children who lacked any ultrasound, clinical, or laboratory evidence of choledocholithiasis had unsuspected CBD stones. Eight children, therefore, had ultrasound, clinical, or laboratory findings not predictive of the actual state of the CBD. Sixteen children underwent endoscopic retrograde cholangiopancreatography (ERCP), 9 preoperatively and 7 postoperatively. Four preoperative ERCP studies showed no CBD stones. There were no complications from performing IOC. CONCLUSIONS: (1) CBD stones are common in children with gallstones, (18 of 100 patients). (2) Preoperative studies and clinical findings may not predict accurately the presence or absence of CBD stones. (3) IOC should be routinely performed in children before the use of ERCP to avoid unnecessary ERCP unless CBD stones are specifically visualized by ultrasound scan. J Pediatr Surg 36:881-884.     

Magnetic resonance cholangiopancreatography accurately detects common bile duct stones in resolving gallstone pancreatitis

BACKGROUND: There is controversy about the optimal method to detect common bile duct (CBD) stones in patients with mild resolving gallstone pancreatitis. The aim of this study was to evaluate magnetic resonance cholangiopancreatography (MRCP) in detecting choledocholithiasis in this group of patients. STUDY DESIGN: A prospective randomized trial was conducted. Patients randomized to group 1 (n = 34) underwent laparoscopic cholecystectomy (LC) and intraoperative cholangiography (IOC). Those randomized to group 2 (n = 29) had preoperative MRCP, of these, patients with negative MRCP underwent LC and IOC, patients with positive MRCP had preoperative ERCP followed by LC. RESULTS: Sixty-three patients were randomized (34 to group 1 and 29 to group 2). CBD stones were found in 5 patients in group 1. CBD exploration was performed in 2 patients, preoperative ERCP in 1, and postoperative ERCP in the other 2. MRCP showed CBD stones in 4 patients in group 2. There were two false-positive MRCPs. Four patients with a negative MRCP did not have IOC or ERCP, the remaining 21 patients with a negative MRCP had a negative IOC. The MRCP sensitivity was 100% (95% CI, 16-100%), specificity 91% (95% CI, 72-99%), positive predictive value 50% (95% CI, 7-93%), negative predictive value 100% (95% CI, 84-100%), and accuracy 92% (95% CI, 74-99%). CONCLUSIONS: Patients with resolving gallstone pancreatitis and a negative MRCP do not need preoperative ERCP or IOC. Only patients with a positive MRCP will require preoperative ERCP.     

胆囊结石合并胆总管结石的微创治疗体会

目的:比较腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)联合腹腔镜胆总管探查术(laparoscopic common bile duct exploration,LCBDE)与内镜逆行胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)、内镜十二指肠乳头括约肌切开术(endoscopic sphincterotomy,EST)+LC治疗胆囊结石合并胆总管结石的临床疗效。方法:在2010年1月至2015年11月收治的胆囊结石合并胆总管结石患者中选取可耐受腹腔镜手术、ERCP且ASA分级为Ⅰ~Ⅱ级的成年患者作为研究对象,危急重症胆囊炎、急性胆管炎及要求保守治疗的患者未纳入研究。分为两组:LC+LCBDE组与ERCP/EST+LC组,比较分析两组患者术中出血量、手术时间、住院时间、住院费用及术后并发症等指标。结果:共纳入76例患者,30例行LC+LCBDE,其中2例中转开腹;46例行ERCP/EST+LC,其中2例因ERCP取石失败,不予统计。两组患者术中出血量、术后并发症差异无统计学意义,LC+LCBDE组手术时间、住院时间、住院费用优于ERCP/EST+LC组,差异有统计学意义。结论:两种术式治疗胆囊结石合并胆总管结石的疗效相当,但LC+LCBDE可能更加经济实惠。     

Endoscopic retrograde cholangiopancreatography in conjunction with laparoscopic cholecystectomy

Summary Laparoscopic cholecystectomy (LC) has become the primary surgical treatment for symptomatic cholelithiasis. In conjunction with the dramatic rise in LC there has been an increase in the number of endoscopic retrograde cholangiopancreatographies (ERCPs) performed. For this study, the records of patients referred to the surgical endoscopy department between January 1991 and February 1992 were reviewed. Seventy-seven ERCPs were performed in conjunction with LC. The indications for ERCP included jaundice or a history of jaundice, gallstone pancreatitis, a suspicious filling defect on either ultrasound or intraoperative cholangiogram, abnormal liver function tests, cholangitis, or postoperative bile leak. Sixty-two procedures were performed prior to LC and 15 procedures after LC. Forty-two patients were female (54.5%) and the patients ages ranged from 14 to 92 years (mean 54.1 years). Of the 62 patients having ERCP preoperatively 35 patients (56.5%) had no evidence of common bile duct (CBD) stones and underwent LC as planned. Twenty-three patients were found to have CBD stones, of which six were referred for an open cholecystectomy and CBD exploration, because of large multiple CBD stones or the presence of a large duodenal diverticulum. Seventeen patients had their CBD cleared endoscopically, and four patients were not successfully cannulated.Fifteen patients had ERCP after LC. There were two patients with CBD injuries who were referred for surgical correction. Two patients had leakage from the cystic duct stump, and four patients had CBD stones, all of whom were successfully treated with endoscopic sphincterotomy. There were four patients who had a normal postoperative ERCP and two patients who could not have their CBD cannulated.There were no mortalities, but there were four cases of complications. Two patients had bleeding after stone extractions, and they required blood transfusions. One patient developed cholangitis from stenosis of the papilla after an endoscopic sphincterotomy, and one patient developed pancreatitis which resolved with conservative treatment. There is an increasing role for ERCP and sphincterotomy in patients undergoing LC. ERCP carries an inherent morbidity and therefore routine ERCP is not justified. However, with the proper suspicion of CBD stones a preoperative ERCP is indicated prior to a planned laparoscopic cholecystectomy.     

The importance of intraoperative cholangiography during laparoscopic cholecystectomy.

Laparoscopic cholecystectomy (LC) using an electrosurgery energy source was successfully performed in 59 (95%) out of 62 selected patients. The procedures were performed by different surgical teams at Trakya University, Medical Fakulty, in the department of General Surgery and the Karl-Franzens-University School of Medicine, in the department of General Surgery. Cholangiography was routine at Karl Franzens University and selective at Trakya University. Laparoscopic intraoperative cholangiography (IOC) was performed in 48 (81.3%) patients, and open IOC was performed in 3 patients. Two patients had common duct stones; one of which was unsuspected preoperatively. These cases underwent endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic papillotomy (EP). One patient had a choledocal tumor, unsuspected preoperatively. Anatomical anomalies were not identified. Cholangiography could not be performed in one case in which there was no suspected pathology. ERCP was performed on one patient 30 days after being discharged because of acute cholangitis. In this case, residual stones were identified in the choledocus. Four patients underwent open cholecystectomy because of tumor, unidentified cystic duct or common bile duct pathology that could not be visualized on the cholangiogram. Our study suggests that cholangiography performed via the cystic duct before any structures are divided can prevent the most serious complication of laparoscopic cholecystectomy--common duct injury. We recommend that cholangiography be attempted on all patients undergoing LC.     

Must ERCP Be routinely performed if choledocholithiasis is suspected?

OBJECTIVE: To evaluate the results of preoperative endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and treatment of those patients suspected of harboring bile duct stones before laparoscopic cholecystectomy (LC). PATIENTS AND METHODS: A total of 1,235 consecutive LCs performed between 1991 and 1997 were studied prospectively. ERCP was performed to explore the common bile duct (CBD) preoperatively when choledocholithiasis was suspected on the basis of clinical, analytical or echographical data. RESULTS: ERCPs were performed in 268 patients: unsuccessful CBD evaluation in 3%; dilated CBD without lithiasis in 13%, and normal exploration in 37% (99 patients). CBD stones were found in 46% (124 patients), and endoscopic sphincterotomy was then performed and stone extraction attempted. Endoscopic therapy achieved 92.8% successful removal of CBD stones (115 patients). There was no ERCP-related mortality and the morbidity rate was 6%. Retained CBD stones have been observed in 7 cases after ERCP-LC; all of them have been successfully treated by ERCP. CONCLUSIONS: A combined approach to bile duct stones with selective use of ERCP followed by LC is a good therapeutical alternative. Nevertheless, the usual selection criteria for ERCP may lead to unnecessary exploration. It appears to be necessary to modify the current diagnostic and therapeutic strategy. Copyright Copyright 1999 S.Karger AG, Basel     

ERCP and laparoscopic cholecystectomy in a combined (one-step) procedure: a random comparison to the standard (two-step) procedure

Background

Current treatment of complicated calculous biliary disease typically involves a two-step procedure consisting of preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy. Alternatively, laparoscopic cholecystectomy with intraoperative cholangiogram (IOC) and intraoperative common bile duct exploration or ERCP at a later date may be performed. This study compared the benefits of the traditional two-step procedure to the novel one-step procedure for the management of calculous biliary disease.

Methods

A retrospective review of 20 patients was conducted comparing one-step to two-step procedures for the management of choledocholithiasis. We define the one-step procedure to be a laparoscopic cholecystectomy with IOC to confirm the presence or absence of stones. Intraoperative ERCP with stone extraction was conducted if necessary as part of the one-step procedure.

Results

A statistically significant difference existed between hospital charges for one-step ($58,145.30, SD $17,963.09) and two-step ($78,895.53, SD $21,954.78) procedures (p = 0.033). Other parameters (length of stay, preoperative days) trended toward significance; however, statistical significance was not achieved.

Conclusions

There appears to be a significant cost reduction with implementation of the one-step treatment of calculous biliary disease. Further research with a larger study population is necessary to determine the additional benefits of this procedure and to help augment the surgical endoscopists’ armamentarium.     

腹腔镜联合内镜逆行胰胆管造影术治疗胆囊结石合并胆总管结石的临床体会

目的:探讨内镜逆行胰胆管造影术(endoscopic retrograde cholangiopancreatography,ERCP)联合腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)治疗胆囊结石合并胆总管结石的最佳组合方式。方法:回顾分析2007年1月至2012年11月为203例胆囊结石合并胆总管结石患者行ERCP+内镜乳头括约肌切开术(endoscopic sphincterotomy,EST)联合LC的临床资料。其中138例先行ERCP+EST取出胆总管结石,再行LC(ERCP+LC组);65例先行LC再行ERCP+EST(LC+ERCP组)。对比分析两组手术成功率、总住院时间及并发症情况。结果:两组均无穿孔、出血及重症胰腺炎等严重并发症发生。ERCP+LC组住院时间短[(7.2±2.1)d vs.(8.1±1.9)d],差异有统计学意义(P<0.05)。ERCP+LC组术后胆管残余结石4例,发生急性轻型胰腺炎1例、胆管炎1例,并发症发生率为4.3%;低于LC+ERCP组的12.3%(P<0.05)。结论:对于胆囊结石合并胆总管结石的患者,先行ERCP+EST取石,再行LC,手术并发症较少,住院时间短,是较理想的组合方式。