The Value of Choledochoscopy in Exploration of the Common Bile Duct

Direct visualization of the biliary tree using choledochoscopy has been recommended as a technique to improve the accuracy of common duct exploration. In several series the incidence of retained biliary calculi has been dramatically reduced using choledochoscopy, and some authors have reported the findings of other unsuspected benign and malignant lesions as well. During an eight-year period 288 patients underwent exploration of the common bile duct specifically for calculous disease. Operative rigid choledochoscopy was performed in 140 patients in this group, with 79 found to have choledocholithiasis; seven retained stones occurred in this group for an incidence of 8.9%. Routine common duct exploration in the other 148 patients revealed 67 to have choledocholithiasis; six retained stones occurred in this group for an incidence of 9.0%. Though there was no difference in the incidence of retained stones with or without choledochoscopy, 20 patients were found to have stones missed during routine exploration once the rigid choledochoscope was inserted. In addition to the obvious value of the choledochoscope in identifying and removing common duct stones, it was also found to be an aid in removing stones in the intra-hepatic ducts and in clarifying atypical anatomy. Other causes of biliary obstruction such as a liver fluke, benign polyp, benign strictures, and ductal carcinomas were identified by use of biopsy forceps inserted through the choledochoscope. It is recommended that routine choledochoscopy be performed during common duct explorations and that surgical training programs insure that residents learn the technique of operative choledochoscopy.     

Choledochoscopy: are stones missed? A controlled study

Although the choledochoscope has been available for several years, its use had not achieved universal acceptance. Enthusiasts claim that the incidence of retained stones in the common bile duct would be reduced by using the instrument, but no controlled study by the same team has been reported. Patients undergoing biliary surgery by one surgical team in Southampton were operated upon in one of three hospitals. The choledochoscope was available for use at only one hospital, but the other two were otherwise fully equipped, and no selection of patients was made for any particular hospital. Over a period of 7 years, 707 patients underwent elective or emergency cholecystectomy. Routine choledochography was performed and stones were found or suspected in the bile ducts in 103 (14.6 per cent). The choledochoscope was used in 54 of the bile duct explorations and in 10 patients residual calculi following routine exploration were identified by the instrument. Postoperative T-tube choledochography was performed in 35 patients following choledochoscopy, 31 with choledocholithiasis at operation, and no unsuspected retained stones were demonstrated. In the 49 patients undergoing duct exploration by the same team without the choledochoscope, 32 were found to have choledocholithiasis. Thirty-six postoperative choledochograms were performed and six patients were found to have retained stones. There were no additional complications attributed to the use of the instrument. We conclude that the use of the choledochoscope should reduce the incidence of retained bile duct stones.     

Choledochoscopy in prevention of retained common bile duct stones

More than 150,000 patients undergo exploration of the common bile duct each year in the United States, and approximately 10 per cent of these patients are later found to have retained common bile duct stones. The usual recommended procedure to decrease the incidence of retained calculi is a more complete exploration of the common duct at time of initial operation. It is thought that the incidence of retained common bile duct stones can be decreased and almost eliminated with proper use of the flexible choledochoscope following intraoperative cystic duct cholangiogram. The technical aspects of choledochoscopy are reviewed and experience with its use in 102 cases between July 1978 and October 1985 is reported. There were no residual stones in the span of the study using the flexible choledochoscope as a routine procedure in common bile duct exploration.     

Operative choledochoscopy in common bile duct surgery.

Surgical exploration of the common bile duct for gallstones is a common operation but carries a high residual stone rate. Conventional techniques for exploring the bile ducts are blind procedures. The surgeon cannot see what he is doing. Also there has been no reliable method for a postexploratory check of the bile ducts before closure, usually around a T-tube. Operative choledochoscopy allows the surgeon to see stones in the duct, may aid the removal of stones and provides visual postexploratory checks that the common bile duct and the hepatic ducts are clear, that papilla is patent and that no stone is left behind before closure. A personal series of 150 patients had operative choledochoscopy using a flexible fibreoptic choledochoscope. If there was a clear indication on preoperative investigations that the ducts should be explored, an operative cholangiogram was omitted and the choledochoscope used as the exploring instrument. In 127 patients with a diagnosis of gallstone disease, choledochoscopy was used at the primary operation. In 12 patients choledochoscopy was used at a secondary operation for recurrent gallstone disease, and 11 patients had malignant obstruction of the biliary tract. In 70 of the 127 patients, gallstones were found and extracted using the choledochoscope. In 53 patients the ducts were clear, and in 4, other lesions were found: 3 papillomas and one polycystic disease. One hundred and six of the patients had the common bile duct closed primarily with no T-tube drainage. There was no increase in complications and no deaths associated with choledochoscopy or primary closure of the common bile duct.(ABSTRACT TRUNCATED AT 250 WORDS)     

Technic for finding and removing stones from intrahepatic bile ducts

Intrahepatic biliary calculi which were missed by routine common duct exploration were discovered by choledochoscopy in the left hepatic ducts of three patients. Removal of stones was accomplished in two of these patients by using instruments for stone extraction under direct vision with the choledochoscope. The use of a Fogarty balloon catheter threaded through the choledochoscope is particularly recommended.     

Impact of choledochoscopy on the management of choledocholithiasis. Experience with 499 common duct explorations at the Massachusetts General Hospital.

This report summarizes the experience with 144 choledochoscopic examinations performed in the course of 499 common bile duct explorations for stones. Routine choledochoscopy added 15--20 minutes to the operation and caused no complications. In 24% of the patients, additional stones were discovered with the choledochoscope after completion of routine bile duct exploration. In spite of this, the incidence of retained stones found postoperatively remained 4%, with or without choledochoscopy. The factors contributing to the failure of choledochoscopy, thus far, to prevent all retained stones are identified as inexperience of surgeons learning to perform biliary endoscopy, failure to scan the biliary tree systematically and thoroughly (including the left hepatic duct), and failure to reach the duodenum with the choledochoscope, meaning failure to see the lower segment of the common duct and ampullary orifice. With a modicum of experience and attention to detail, it should be possible to reduce considerably further the number of retained stones.     

Choledochoscopy as a complementary procedure to operative cholangiography in biliary surgery

Six years' experience with the use of the flexible choledochoscope for biliary surgery is reported. One hundred forty-nine patients underwent common bile duct exploration with choledochoscopy as a complementary procedure. Choledochoscopy immediately showed the absence of stones in 37 patients in whom stones were suspected but the results of preexploratory operative cholangiography were negative or equivocal. The remaining 112 patients underwent choledocholithotomy with choledochoscopy. Only two patients (1.3 percent) returned with unsuspected residual stones.Choledochoscopy used as a complementary procedure to operative cholangiography can easily and more accurately clarify suspicious findings in the operative cholangiogram. It avoids the use of blind instrumental exploration of the bile ducts. Impacted stones can be extracted easily under direct vision with the choledochoscope. We believe that the use of choledochoscopy contributed to our low incidence of retained stones.     

TECHNIQUE AND RESULTS OF LAPAROSCOPIC CHOLEDOCHOTOMY FOR THE MANAGEMENT OF BILE DUCT CALCULI

Laparoscopic choledochotomy has been performed in 50 patients to remove common bile duct calculi demonstrated on routine operative cholangiography at the time of laparoscopic cholecystectomy. The patients ranged from 16 to 91 years old. One patient died, giving a mortality of 2%. At postoperative T-tube cholangiography, retained stones were demonstrated in three patients (6%) with all stones being removed using a choledochoscope via the T-tube track. Laparoscopic common bile duct exploration via a choledochotomy is a feasible and effective method to manage common bile duct calculi demonstrated during laparoscopic cholecystectomy.     

胆总管结石残留的因素分析及防治

目的 探讨胆囊结石胆囊切除术后胆总管结石残留的原因及处理方法。方法 1994年1月2000年9月间1027例胆囊结石病人在我院施行胆囊切除术,同时行胆总管切开探查术者246例,证实有胆总管结石者205例;对其中14例术后胆总管结石残留患者的临床资料进行对比分析。结果 结石残留组病人的76％为60岁或以上,64％并发急性胆管炎,50％术中取出胆总管结石3－5枚,仅14％行术中纤维胆道镜探查取石,与无结石残留病人相比差异均有显著性意义（P＜0．05）。13例残留结石经术后胆总管T管造影发现并分别行1－2次术后纤胆镜取石后完全清除;另1例自然排出。结论 胆总管结石残留多发生于年龄较大、胆总管结石较多、并发急性胆管炎的患者;术中纤胆镜的应用有助于防止结石残留。胆总管T管造影能可靠地诊断残留结石。术后经T管瘘道纤胆镜取石是治疗残留结石安全有效的方法。     

Intraoperative flexible choledochoscopy for intrahepatic and extrahepatic biliary calculi

This prospective study evaluates the use of intraoperative flexible choledochoscopy in the detection and removal of additional stones after conventional bile duct exploration. The biliary system of 109 patients was examined with an Olympus CHF-B4 choledochoscope after conventional methods of exploration. Sixty-five patients had only common duct stones and 44 patients had intrahepatic stones with or without stones in the common duct. Additional stones were detected in 11 patients (16.9%) in the group with common duct stones; eight of these patients had their stones completely removed. Unsuspected residual stones were discovered by means of postoperative cholangiography in three more patients (4.6%); thus the total number of patients with residual stones was six (9.2%). Additional stones were detected in 39 patients (88.6%) in the group with intrahepatic stones. Of these, only 13 patients managed to be freed of stones with the use of the choledochoscope. A further 10 patients underwent liver resection to achieve stone clearance. Unsuspected retained stones were found postoperatively in seven of the 28 patients (25%) whose biliary systems were considered clear of stones. The overall number of patients with retained stones in the group with intrahepatic stones was 23 (52.3%). We concluded that intraoperative flexible choledochoscopy is useful in detecting intrahepatic stones left behind after conventional exploration. However, complete removal of the stones is difficult to achieve.     

腹腔镜下胆道镜联合液电碎石经胆囊管治疗胆总管巨大结石的临床分析

目的:探讨腹腔镜下胆道镜联合液电碎石经胆囊管治疗胆道巨大结石的疗效。方法:回顾分析2005年1月至2013年11月84例因梗阻性黄疸、胆总管巨大结石行腹腔镜下胆道镜联合液电碎石经胆囊管取石患者的临床资料。结果:80例成功完成手术。1例因胆道出血中转开腹行胆总管切开止血、取石+T管引流术;1例患者怀疑胆道下段肿瘤中转开腹探查并行胰十二指肠切除术,术中冰冻病理证实为胆管癌;1例患者经胆囊管取石毕发现乳头下端狭窄,术中行内镜逆行胰胆管造影及乳头肌切开后胆汁流出通畅;1例患者因Mirizzi综合征导致胆囊三角区粘连紧密从而中转开腹行胆总管切开取石、T管引流术。术后均无出血、胆漏、胆总管损伤等并发症发生,术后住院7~11 d。结论:腹腔镜下胆道镜联合液电碎石经胆囊管取石术治疗胆总管巨大结石安全、可靠,手术微创,结石清除率高,并发症少;对于胆囊管粗短直、入口较大的患者,可直接置入胆道镜探查取石,损伤小,优点突出,值得临床应用。     

Operative common bile duct imaging by operative cholangiography and flexible choledochoscopy.

A consecutive series of 108 common bile duct (CBD) explorations was studied to examine the efficacy of routine operative cholangiography and flexible choledochoscopy in the identification of choledocholithiasis. CBD exploration was performed according to the findings of routine operative cholangiography. Nine negative explorations were performed, only one of which would have been avoided had selective cholangiography been employed. Eight patients had unsuspected choledocholithiasis that would have been missed if selective operative cholangiography had been used. Flexible choledochoscopy identified CBD stones on 97 occasions; no additional retained stones were found on subsequent T tube cholangiography. In two cases stones were seen but could not be removed; immediate identification allowed planning for early removal. Flexible choledochoscopy is the most effective method of CBD exploration and should be used in all patients with suspected choledocholithiasis.     

Choledochoscopy. A cost-minimization analysis.

Although choledochoscopy for the prevention of retained bile duct stones has been postulated as cost effective, no economic evaluation exists to substantiate this claim. We performed a cost-minimization analysis on 287 patients who underwent choledochoscopy during operations for biliary tract calculi between 1981 and 1987 to assess the economic impact of choledochoscopy versus noncholedochoscopic alternatives in obtaining a stone-free duct. Common duct exploration was positive for calculi in 75% of patients. Choledochoscopy-detected residual stones after duct exploration in 10% of patients. Residual stones were more frequent after positive (12.5%) than negative (2.7%) duct explorations. retained stones occurred in 4.5% of patients after operation. Sensitivity, specificity, and negative predictive values of choledochoscopy were 67%, 100%, and 95%, respectively. Cost-minimization analysis showed that total cost of either selective ($75,250) or routine ($110,450) choledochoscopy significantly exceeded the total cost of obtaining a stone-free duct for patients with retained stones via either extraction through a T-tube tract ($17,545) or by endoscopic papillotomy ($45,675). Because choledochoscopy was not economically competitive with noncholedochoscopic, nonoperative alternatives, reduction of choledochoscopy fees was implemented to economically justify continued use of choledochoscopy. We conclude that choledochoscopy is clinically efficacious in obtaining a stone-free duct, but endorsement of either routine or selective choledochoscopy by cost-minimization analysis requires careful assessment of fee structure to make choledochoscopy competitive economically.     

Percutaneous flexible choledochoscopy: a simple method for retained common bile duct stone removal

Conventional methods of treatment of retained common bile duct stones found on T tube cholangiography after common bile duct exploration include percutaneous extraction under fluoroscopic control and endoscopic sphincterotomy. Four cases of percutaneous stone extraction under direct vision using the flexible choledochoscope are described. Clearance of the bile ducts was achieved at one sitting in three cases and four sittings in one case. Follow-up tube cholangiography was performed in two cases and confirmed complete clearance. Percutaneous endoscopic stone extraction can be performed by any surgeon with experience of flexible choledochoscopy and offers the advantages of a minimally invasive procedure without the use of specialized equipment.     

Operative choledochoscopy.

We have reported the results of 121 examinations with the rigid choledochoscope performed by 13 different surgeons between 1969 and 1977. Pre-exploratory choledochoscopy was performed in 48 patients with a diagnostic accuracy of 94 per cent. Post-exploratory choledochoscopy was used in 73 patients to define whether the common bile duct had been adequately cleared of stones. Fifty-one patients were correctly assessed as having a clear duct and unsuspected residual calculi were demonstrated by choledochoscopy in 13 patients. However, choledochoscopy failed to identify 9 patients with retained stones. The accuracy of post-exploratory choledochoscopy alone was 87 per cent and the accuracy of post-exploratory cholangiography was 82 per cent, but when choledochoscopy was combined with post-exploratory cholangiography there were no errors. We conclude that the addition of choledochoscopy to conventional radiological techniques is likely to reduce the incidence of residual calculi after choledochotomy.     

Diagnostic and therapeutic choledochoscopy

Laparoscopic cholecystectomy and common bile duct exploration are common surgical procedures for the general surgeon. To successfully remove common bile duct stones, choledochoscopy is an important technique for efficient and effective management. The choledochoscope can be introduced intraoperatively through the cystic duct or directly into the common bile duct and it also can be inserted transhepatically through a T-tube tract and per orally using a therapeutic duodenoscope. All of these methods allow for many options for the surgeon to consider, and one must be familiar with each of these techniques to maximize care. Successful stone extraction with the choledochoscope can be achieved in 75% to 95% of the cases with a morbidity less than 5%. Using this technique, the surgeon can improve the cost benefit of bile duct exploration.     

腹腔镜联合胆道镜胆总管探查取石一期缝合术46例报告

目的:探讨腹腔镜联合胆道镜胆总管探查取石一期缝合术的手术方法、适应证,并评估其安全性及手术价值。方法:回顾分析2005年1月至2010年1月为46例患者施行腹腔镜联合胆道镜胆总管探查取石一期缝合术的临床资料。结果:46例手术均获成功,术后无结石残留;1例发生胆漏,经急诊ERCP置入胆道支架治愈;术后无胰腺炎发生。随访6～36个月,无残余结石及胆管狭窄。结论:腹腔镜联合胆道镜胆总管探查取石一期缝合术可作为治疗胆总管结石的常规术式,术中可彻底取净结石,防止结石残留。     

Extent of choledochoscopic utilization in common bile duct exploration

Various reports have demonstrated that the intraoperative utilization of the choledochoscope has significantly reduced the incidence of unsuspected retained common duct stones from approximately 10 percent to 0 to 2 percent. Our series revealed a 4 percent incidence of retained stones before choledochoscopy was utilized. This incidence was reduced to 1.1 percent after it was employed. Since the availability of the choledochoscope is unknown, all hospitals in Alabama with 60 or more beds (total of 86) were surveyed to determine the rate of choledochoscopic utilization. Although this instrument was noted to be readily available in many of those institutions with greater than 150 beds (47 percent), only 25 (29 percent) of all the hospitals surveyed had the choledochoscope. Furthermore, only 17 (20 percent) of all hospitals used the instrument routinely for common duct exploration. Although the rate of retained common bile duct stones in Alabama is unknown, it is probably similar to the 10 percent average reported. Consequently, it is believed that wider acceptance of the choledochoscope will reduce the incidence and associated morbidity of retained common bile duct stones.     

腹腔镜联合胆道镜治疗有上腹部手术史的肝外胆管结石63例分析

目的探讨有上腹部手术史病人行腹腔镜联合胆道镜治疗肝外胆管结石的可行性及临床疗效。方法回顾性分析2013年4月至2017年3月期间对63例有上腹部手术史的胆总管结石病人采用腹腔镜胆总管切开探查、术中胆道镜取石、T管引流术或鼻胆管引流胆总管一期缝合术治疗的临床资料。结果腹腔镜手术成功60例;中转开腹3例。16例取石后T管引流,41例取石后放置鼻胆管引流一期缝合胆总管,6例经胆囊管胆总管探查胆道镜取石一期缝合。术后胆漏2例,无出血、腹腔感染等并发症发生。61例随访4~48个月,2例失访,无结石残留、胆管狭窄发生。结论术前影像学的准确评估,术者娴熟的腹腔镜及胆道镜手术技巧,以及对中转手术时机的严格掌控,术后的通畅引流,能够使有上腹部手术史的肝外胆管结石病人在进行腹腔镜联合胆道镜治疗时安全可行。     

腹腔镜肝左外叶切除联合胆道镜治疗肝左外叶为主的结石23例

目的探讨腹腔镜肝左外叶切除联合术中应用胆道镜在治疗肝左外叶肝内胆管结石中的可行性及安全性。方法 2014年11月至2016年10月对23例肝左外叶为主的肝内胆管结石病人行腹腔镜肝左外叶切除联合胆道镜检查及取石,其中9例病人合并胆总管结石,合并胆囊结石11例,同时合并胆总管结石及胆囊结石7例,合并肝左内叶结石3例。结果 23例病人均成功行腹腔镜下肝左外叶切除,并通过肝断面胆管经胆道镜对肝内胆管及胆总管检查、取石,9例病人通过胆道镜取出胆总管内结石,11例病人联合胆囊切除,3例病人通过胆道镜取出肝左内叶结石。所有病人手术顺利,手术时间为142~188 min,平均(157±27)min;术中出血量为150~550 ml,平均(240±52)ml;胃肠功能恢复时间为1~3 d,平均(1.7±0.6)d;术后住院时间为7~13 d,平均(9.0±2.2)d。术后1例病人发生肝断面渗血,2例病人发生胆漏,均经保守治疗治愈。术后随访病人3~24个月,均未见结石残留及复发。结论腹腔镜肝左外叶切除联合术中应用胆道镜治疗肝左外叶肝内胆管结石具有疼痛轻、恢复快、残石率低的优势,是一种安全、可行的手术方式,可在临床中广泛应用。