Early versus delayed single-stage laparoscopic eradication for both gallstones and common bile duct stones in mild acute biliary pancreatitis

Several studies addressed that preoperative endoscopic retrograde cholangiopancreatography (ERCP) for common bile duct (CBD) clearance, followed by interval laparoscopic cholecystectomy (two-stage approach), constitutes the most common practice in cases of uncomplicated mild acute biliary pancreatitis. Between June 1998 and December 2002, 44 patients (35 females and 9 males with a median age of 62 years) suffering from uncomplicated mild acute biliary pancreatitis were treated in our unit. All patients were electively submitted to surgery after subsidence of the acute symptoms, and for definitive treatment we favored the single-stage laparoscopic management, avoiding preoperative ERCP. All patients underwent laparoscopic cholecystectomy plus fluoroscopic intraoperative cholangiogram (IOC). If filling defect(s) were detected in the IOC, a finding suggestive of concomitant choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) was added in the same sitting. Twenty patients were operated upon within 2 weeks since the attack of the acute symptoms and constitute the early group (n=20), whereas 24 patients underwent an operation later on and constitute the delay group (n=24). We retrospectively compare the safety, effectiveness, and outcome after the single-stage laparoscopic management between the two groups of patients. Laparoscopic cholecystectomy alone constituted the definitive treatment in 38 patients, while an additional LCBDE was performed in the remaining 6 patients (14%), and all operations were achieved laparoscopically. There was no statistically significant difference between the groups in terms of operative time, incidence of concomitant choledocholithiasis, morbidity rate, and postoperative hospital stay. During the follow-up, none of the patients experienced recurrent pancreatitis. In uncomplicated mild acute biliary pancreatitis cases, a single-stage definitive laparoscopic management, avoiding preoperative ERCP, can be safely performed during the same admission, after the improvement of symptoms and local inflammation. Postoperative ERCP should be selectively used in patients in whom the single-stage method failed to resolve the problem.     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

Fluorocholangiography: reincarnation in the laparoscopic era—evaluation of intra-operative cholangiography in 3635 laparoscopic cholecystectomies

Background

The introduction of laparoscopic cholecystectomy (LC) resulted in the decline of routine intra-operative cholangiography (IOC). Common bile duct stones are being diagnosed preoperatively using magnetic resonance cholangiopancreatography (MRCP). We aim to evaluate the use and benefits of IOC during laparoscopic biliary surgery at a high-volume biliary surgery unit.

Methods

Prospective data from 4088 patients undergoing LC over 22 years were analysed. Referral protocols allow one firm to receive the great majority of biliary emergencies and all suspected ductal stones. All patients with gall stones on ultrasound scanning, fit for surgery, will undergo LC during the index admission. MRCP and ERCP are not part of preoperative investigation. A four-port LC is performed with a size 5Fr ureteric catheter within an open cannula to obtain an IOC through right sub-costal port.

Results

Of 4088 patients, IOC was attempted in 3691 (90.2 %) and 3635 had a successful IOC (98.4 %). 75 % were females. The mean age was 59 years. Patients presented with one or more of the following: chronic biliary pain in 60 %, acute pain 26.7 %, acute cholecystitis 8.4 %, gallstone pancreatitis 7.8 % and jaundice with or without cholangitis in 19.2 %. A total of 1328 patients (36.5 %) had risk factors for CBD stones. The IOC was abnormal in 975 cases (26.8 %), recording 1599 abnormalities. IOC identified 774 patients with CBD stones (21.3 %), including previously unsuspected CBD stones in 4.7 %. IOC was false negative in 20 cases (0.5 %) found to have stones on basket exploration. A decision not to perform IOC in 453 cases (11 %) was made preoperatively in 74.2 % and intra-operatively in 12.3 %.

Conclusion

IOC can be safely and routinely performed in LC. It helps to identify CBD stones, even in patients with no known risk factors, delineate bile duct anatomy and facilitate single-stage management of CBD stones.

     

Limitations of fluoroscopic intraoperative cholangiography in cases suggestive of choledocholithiasis

BACKGROUND: Fluoroscopic intraoperative cholangiography (IOC) has been proposed as a safe and accurate screening method for choledocholithiasis, with a sensitivity and specificity of nearly 100% in selected cases. In the present study we retrospectively reviewed the diagnostic accuracy of IOC in cases highly suggestive of choledocholithiasis. MATERIALS AND METHODS: Between January 1999 and December 2002, 103 patients underwent IOC as an imaging method for common bile duct (CBD) stone detection. We did not routinely perform IOC in all patients who were submitted to laparoscopic cholecystectomy, reserving the method for patients with a high probability of choledocholithiasis, namely patients with a history or the presence of painful obstructive jaundice at the time of referral, patients with a history of mild acute pancreatitis of biliary origin, and patients with abnormalities in their liver biochemistry profile as measured by liver function tests (LFT). RESULTS: The mean rates of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for IOC were 98%, 94%, 94.5%, and 98% for the whole series, respectively. The diagnostic accuracy was 100% in patients with a history of obstructive jaundice or liver biochemical derangement, but was less in patients with a history of biliary pancreatitis. There were 3 false positive cases and 1 case of false negative results, all of which occurred in the subgroup of patients with a history of pancreatitis. CONCLUSION: Selective fluoroscopic IOC is generally feasible and safe, as well as highly accurate (100%) for CBD stone detection in patients with obstructive jaundice or abnormal LFT. The PPV of the method decreases in patients with a history of pancreatitis (75%), while a negative result is highly suggestive of the absence of CBD stones (NPV = 98%). The present study concluded in a higher incidence of false results in patients with a normal size CBD, suggesting that the diagnostic accuracy of IOC is probably related to the size of the CBD rather than the indication for its performance.     

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.     

Acute biliary pancreatitis: Diagnosis and management

Acute biliary pancreatitis is a serious complication of biliary calculous disease and is associated with significant morbidity and mortality. The role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of acute biliary pancreatitis has been the focus of discussion in recent years. In addition, the exact role of laparoscopic cholecystectomy (LC) in the management of acute biliary pancreatitis has not yet been fully defined. In this report, we evaluated a protocol of emergency ERCP (within 24 hours) for predicted severe attacks, early ERCP (within 72 hours) for predicted mild attacks, and interval LC for management of acute biliary pancreatitis. Between January 1992 and June 1995 a total of 75 patients with acute biliary pancreatitis were managed according to the protocol. Bedside ultrasonography at admission diagnosed 94% of all 64 patients with gallbladder stones, but the sensitivity of visualizing choledocholithiasis was low (19%). Forty-five (60%) of them were predicted to have a severe attack by either Ranson or glucose/urea criteria. Emergency ERCP and endoscopic sphincterotomy (ES) for identifiable common bile duct (CBD) or ampullary stones were performed on all patients predicted to have a severe attack within 24 hours from presentation. An early endoscopic procedure was performed on all patients predicted to have a mild attack within 72 hours from presentation. ERCP was successful in 95% of all patients, and CBD stones were detected in 52 (69%) of them. ES and stone clearance were successful in all of these 52 patients. The morbidity associated with the endoscopic procedure was 3%, and there were no deaths. All except one patient survived the attack of acute pancreatitis, resulting in an overall mortality of 1%. Interval LC was performed on 46 patients with a conversion rate of 4%. The median postoperative hospital stay after LC was 2 days, and there was no major intraoperative or postoperative morbidity or mortality. Our experience suggests that the policy of emergency ERCP for patients with predicted severe disease, early ERCP for patients with predicted mild disease, and interval LC are associated with favorable outcomes in patients with acute biliary pancreatitis. Acute biliary pancreatitis can be managed safely and effectively by a combined endoscopic and laparoscopic approach.     

The role of endoscopic retrograde cholangiopancreatography in management of patients recovering from acute biliary pancreatitis in the laparoscopic era

Background: Traditionally an episode of acute biliary pancreatitis (ABP) is an indication for direct imaging of the biliary tree. The optimal approach may vary according to local expertise, and endoscopic retrograde cholangiopancreatography (ERCP) is the most common. The fact that the incidence of choledocholithiasis in patients recovering from ABP varies between 3 and 33% raises a question about the necessity of visualizing the biliary tree in all patients recovering from ABP. Methods: In order to evaluate this policy, we reviewed 48 ERCPs performed on patients recovering from ABP who were scheduled for laparoscopic cholecystectomy (LC). We checked the correlations between ERCP findings and the severity of pancreatitis, biochemistry values (which were sampled during the acute phase), and ultrasonographic (US) findings. Results: The ERCP demonstrated common bile duct (CBD) stones in 11 (22.9%) patients. US finding of a dilated CBD and maximal aspartate transaminase (AST) values higher than 90 units/l were significantly correlated with CBD stones (a relative risk [RR] of 2.95 with a 95% confidence interval [CI] for a dilated CBD and RR of 3.89 with a 95% CI of 1.18–12.80 for an AST value higher than 90 units/l). No other parameters were significantly correlated with CBD stones. Conclusion: We, therefore, recommend performing a preoperative ERCP only on patients who present with an ultrasonographic finding of CBD dilatation. The correlation to high AST is still to be proven.     

Timing of endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy in the treatment of choledocholithiasis

Although experience with laparoscopic approaches to common duct stones is increasing, endoscopic retrograde cholangiopancreatography (ERCP) performed either before or after laparoscopic cholecystectomy (LC) remains the most common approach. Debate remains as to the best timing for ERCP in patients with suspected choledocholithiasis. Because clinical, laboratory, and radiological data are poor predictors of choledocholithiasis, many ERCPs done before LC give negative results. ERCP performed after LC with a positive intraoperative cholangiogram (i.o.p.) would eliminate many unnecessary preoperative endoscopic studies. This is a retrospective analysis of the treatment of choledocholithiasis with the combination of LC and ERCP. All patients included could have had ERCP preoperatively or postoperatively; therefore, those with cholangitis requiring emergent preoperative ERCP were excluded. Two groups of patients were compared: those who underwent ERCP followed by LC and those who underwent LC and IOC followed by ERCP. No significant differences were found with respect to age, gender, health status, clinical presentation, laboratory values (most liver functions, white blood cell count, hemoglobin, and serum amylase), surgery time, blood loss, ERCP time, time between treatment modalities, and days to regular diet. However, the preoperative ERCP group was found to have a longer hospital stay (6.7 days vs. 3.5 days, p = 0.003) and higher hospital cost ($9,406.39 vs. $12,816.23, p = 0.05). The preoperative ERCP group had two patients requiring two ERCPs to clear the common duct, one patient requiring conversion to open procedure because of failed LC, and four minor complications. The postoperative ERCP group had no failed LC, IOC, or postoperative ERCPs and one minor complication. The rate of false positive IOC was 6.7% and of negative preoperative ERCP, 43%. We conclude that in the absence of cholangitis requiring emergent endoscopic decompression, suspected choledocholithiasis can be successfully managed first with LC, ERCP being reserved for patients with a positive IOC. This eliminates many negative preoperative ERCPs.     

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     

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.     

Effect of intraoperative cholangiography during cholecystectomy on outcome after gallstone pancreatitis

Acute gallstone pancreatitis has traditionally been managed by early cholecystectomy with intraoperative cholangiography (IOC). To evaluate the effect of IOC on patient outcome, we analyzed all patients operated on for acute gallstone pancreatitis at our institution over a 3-year period. A total of 200 patients (37 open, 163 laparoscopic) were evaluated. Nineteen of 34 patients who underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP) were found to have common bile duct (CBD) stones. The 59 patients who underwent cholecystectomy with IOC had significantly longer operative times compared to the 141 patients who underwent cholecystectomy alone (167 vs. 105 minutes for open [P= 0.008] and 89 vs. 68 minutes for laparoscopic [P< 0.0001] operations). Of the 59 patients who underwent IOC, only nine (15%) had abnormal cholangiograms, and CBD exploration in seven revealed stones in four patients, edematous ampullae in two, and no abnormality in one. Six of eight patients (5 IOC, 3 no IOC) who required immediate postoperative ERCP were noted to have CBD stones. Patients who underwent IOC had significantly longer postoperative hospital stays (3.8 vs. 2.0 days [P= 0.007]). The incidence of retained CBD stones following surgery was similar (5.1% IOC, 2.8% no IOC). Although 7 of 122 patients who underwent laparoscopic cholecystectomy without IOC were readmitted, only one was found on ERCP to have a retained CBD stone. Age, sex, preoperative days, procedure type, and biliary-pancreatic complications after discharge did not differ significantly between patients with and without IOC. We conclude that IOC in patients operated on for acute gallstone pancreatitis results in a longer operative time and a prolonged postoperative course, but has no effect on the incidence of retained CBD stones. Presented at the Annual Meeting of the Southern California Chapter of the American College of Surgeons, Huntington Beach, California, January 21–23, 2000.     

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     

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。     

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.