Is ERCP manometry useful in the choice of treatment of stones of the common bile duct?

Summary To verify the appropriateness of sphincterotomy as the treatment of choice of choledocholithiasis, since 1980 we have been using endoscopic retrograde cholangiopancreatographic (ERCP) manometry of the sphincter of Oddi (SO). This method allows direct investigation of SO motor activity and provides useful information regarding the presence of benign papillary stenosis (BPS). Thirty-four patients were investigated because the radiological examination indicated BPS might be present. Of these, 20 had common bile duct (CBD) stones, while the remaining 14 presented with biliarylike pain and one or more of the following: CBD dilation (larger than 12 mm); emptying of the ERCP contrast medium took longer than 45 min; abnormal liver function tests. Moreover, 8 healthy volunteers served as controls. Our results show that the incidence of SO motor anomalies is very low in the presence of choledocholithiasis, while it is substantial in patients with suspected SO dysfunction. These observations would suggest that, unlike the traditional view, BPS is rarely secondary to biliary lithiasis. Therefore, most of the sphincterotomies performed that are based on the assumption of underlying SO pathology should be considered unnecessary. Under these circumstances, the physiological role of a functioning SO has induced us to advocate sphincterotomy, surgical or endoscopic, in selected cases only.     

Can ultrasound common bile duct diameter predict common bile duct stones in the setting of acute cholecystitis?

Background

Our aim is assessment of ultrasound (US) common bile duct (CBD) diameter to predict the presence of CBD stones in acute cholecystitis (AC).

Methods

A retrospective review from 2007 to 2011 with codes for ultrasound, magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography, and AC was conducted.

Results

The incidence of CBD stones was 1.8%. Two hundred forty eight individuals had US+MRCP+ERCP+AC, of which 48 had CBD stones and 200 did not have CBD stones. US CBD diameter range was 3.6 to 19 mm. Ninety percent of MRCPs were negative, and it delayed care by 2.9 days. Mean CBD diameter was narrower in those negative for CBD stones (5.8 vs 7.08; P = .0043). Groups based on diameter ranges <6, 6 to 9.9, and ≥10 mm demonstrated 14%, 14%, and 39% CBD stones, respectively.

Conclusions

US CBD diameter is not sufficient to identify patients at significant risk for CBD stones. MRCP delayed care by 2.9 days. Intraoperative cholangiography may be more effective, based on the low risk of CBD stones in AC.     

Low conjunction of the cystic duct with the common bile duct: does it correlate with the formation of common bile duct stones?

Background This study aimed to evaluate the accuracy of magnetic resonance cholangiography (MRC) in detecting variants of low cystic duct conjunction, which can be a source of confusion during surgery when unrecognized. Methods All cases with both MRC and endoscopic retrograde cholangiography (ERC) indicating suspected common bile duct stones between January 1999 and January 2004 were retrospectively reviewed by investigators blinded to the final diagnosis. Assessment with ERC was regarded as the gold standard. The aim was to find a low conjunction of the cystic duct with the bile duct. The sensitivity and specificity of MRC were calculated in comparison with those for ERC. The cystic junction radial orientation was defined as lateral (insertion diagonally from the right), medial (insertion into the left side of the common hepatic duct), or posteroanterior (overlap of the junction with the bile duct in the posteroanterior view). A spiral cystic duct and a long parallel course were evaluated separately. Results Low insertion of the cystic duct was found on ERC in 66 of 622 patients (11%; 28 men and 38 women; mean age, 64.5 years). The sensitivity and specificity of MRC for detecting low cystic entrance were 100% (90.4% on an intention-to-diagnose basis and 100%, respectively). In 11 patients (16.6%), the radial orientation of the cysticohepatic junction could not be defined with MRC. The rate of correct MRC delineation was 95% for lateral (n = 21), 77% for medial (n = 26), and 74% for posteroanterior (n = 19) insertion of the cystic duct. Conclusion The findings showed that MRC has good correlation with ERC with regard to the location and anatomic details of cystic duct insertion. Although this does not generate a separate indication for MRC before laparoscopic cholecystectomy, the anatomic information can be of additional use when MRC is clinically indicated in this setting.     

Does the surgeon’s experience influence the outcome of laparoscopic treatment of common bile duct stones?

Background

The aim of this study was to assess laparoscopic treatment of choledocholithiasis with respect to the surgeon’s experience.

Methods

From January 1994 to December 2006, 130 patients underwent laparoscopic treatment for common bile duct stones found with intraoperative cholangiography. Two types of surgeons were defined: junior surgeons with fewer than ten laparoscopic common bile duct explorations performed and experienced surgeons with more than ten. The two patient populations (n = 65 in each group) were similar in regard to demographic data, clinical presentations (complicated or not), and ASA score.

Results

Results show that junior surgeons had significantly more patients with a common bile duct (CBD) diameter <7 mm compared to experienced surgeons (66 % vs. 38 %; p = 0.002). Primary closure of choledochotomy was performed by senior rather than junior surgeons significantly more often (87.5 % vs. 69 %; p = 0.05). Mean operating time was found to be longer for junior operators than for experienced surgeons (220 ± 71 min vs. 169 ± 71 min; p = 0.0006). There was no difference between group 1 (juniors) and group 2 (experienced surgeons) in regard to laparotomy conversion rate (9 % vs. 1.5 %; p = 0.1), complete common bile duct clearance (98 % vs. 100 %, p = ns), postoperative complications (two bile leaks in group 1 and one in group 2), and hospital stay (9 days vs. 7.5 days). In multivariate analysis, the transcystic approach was not influenced by the surgeon’s experience. Experienced surgeons performed choledochotomy with primary closure more easily [RR = 3 (range = 1.1–8); p = 0.04]. Complicated presentations [RR = 2 (0.7–3); p = 0.08] and CBD diameter [RR = 2.5 (0.96–7); p = 0.06] influenced the choice of type of closure of choledochotomy without any significant value.

Conclusion

Surgeon’s experience influenced operating time and type of choledochotomy closure performed but had no influence on postoperative results of the laparoscopic treatment of common bile duct stones.     

Stenting or surgery for treatment of irretrievable common bile duct calculi in elderly patients?

BACKGROUND: The value of endoprostheses for long-term management of bile duct stones has not been formally established. We retrospectively compared the results of this method versus surgical approach in elderly patients (>70 years) with endoscopically irretrievable bile duct stones. METHODS: From January 1990 to September 1998, 68 patients over 70 years old underwent endoscopic biliary stenting (group A: 31 patients) or surgery (group B: 37 patients) for endoscopically irretrievable bile duct stones. The groups were similar with regard to gender, age, clinical presentation, ASA score, and number and size of the stones. RESULTS: Successful biliary drainage was achieved in 31 of 31 patients of group A and 37 of 37 patients of group B. Early complications occurred in 12.9% of group A versus 29.7% of group B (P <0.005) and early mortality was 0% in group A versus 2.7% of group B (P = NS). Over the long-term follow-up, late complications occurred in 35.5% of group A versus 8.1 % of group B (P <0.001). Three cases of biliary-related death occurred in group A versus 0 in group B (9.6% versus 0%: P <0.005). CONCLUSIONS: For immediate bile duct drainage endoprostheses proved a safe and effective alternative to surgery in elderly patients with endoscopically irretrievable bile duct stones. Because of the risk of subsequent complications, their use as a definitive treatment should be restricted to highly selected cases.     

The clinical significance of bile duct sludge: is it different from bile duct stones?

Background Some patients with suspected common bile duct (CBD) stones are found to have sludge and no stones. Although sludge in the gallbladder is a precursor of gallbladder stones, the significance of bile duct sludge (BDS) is poorly defined. This study aimed to compare BDS with bile duct stones in terms of frequency, associated risk factors, and clinical outcome after endoscopic therapy. Methods The study enrolled 228 patients who underwent therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for suspected choledocholithiasis. The patients were divided into two groups: patients with BDS but no stones on ERCP and patients with CBD stones. The presence of risk factors for bile duct stones (age, periampullary diverticulum, ductal dilation or angulation, previous open cholecystectomy) were assessed at ERCP. Follow-up data (36 ± 19 months) were obtained from medical records and by patient questioning. Results Bile duct sludge occurred in 14% (31/228) of patients and was more common in females. After endoscopic clearance, CBD stones recurred in 17% (33/197) of the patients with CBD stones, and in 16% (5/31) of the patients with BDS (p = 0.99). Common bile duct dilation was less common in the sludge group. The other known risk factors for recurrent CBD stones (age, previous open cholecystectomy, bile duct angulation, and the presence of a peripampullary diverticulum) were not statistically different between the two groups. Conclusions The findings indicate that the clinical significance of symptomatic BDS is similar to that of CBD stones. Bile duct sludge seems to be an early stage of choledocholithiasis. D. Keizman and M. Ish-Shalom have equally contributed to this study     

Surgeons,ERCP, and laparoscopic common bile duct exploration: do we need a standard approach for common bile duct stones?

Background

Variation exists in the management of choledocholithiasis (CDL). This study evaluated associations between demographic and practice-related characteristics and CDL management.

Methods

A 22-item, web-based survey was administered to US general surgeons. Respondents were classified into metropolitan or nonmetropolitan groups by zip code. Univariate tests and multivariable logistic regression were used to determine factors associated with CDL management preferences.

Results

The survey was sent to 32,932 surgeons; 9902 performed laparoscopic cholecystectomy within the last year; 750 of 771 respondents had a valid US zip code and were included in the analysis. Mean practice time was 18 ± 10 years, 87 % were male, and 83 % practiced in a metropolitan area. For preoperatively known CDL, 86 % chose preoperative endoscopic retrograde cholangiopancreatography (ERCP). Those in metropolitan areas were more likely to select preoperative ERCP than those in nonmetropolitan areas (88 vs. 79 %, p < 0.001). For CDL discovered intraoperatively, 30 % selected laparoscopic common bile duct exploration (LCBDE) as their preferred method of management with no difference between metropolitan and nonmetropolitan areas (30 vs. 26 %, p = 0.335). The top reasons for not performing LCBDE were: having a reliable ERCP proceduralist available, lack of equipment, and lack of comfort performing LCBDE. Factors associated with preoperative ERCP were: metropolitan status, selective intraoperative cholangiography (IOC), and availability of a reliable ERCP proceduralist. Those who perform selective IOC were 70 % less likely to prefer LCBDE (OR 0.32, 95 % CI 0.18–0.57, p < 0.001). Those with a reliable ERCP proceduralist available were 90 % less likely to prefer LCBDE (OR 0.10, 95 % CI 0.04–0.26, p < 0.001).

Conclusions

The majority of respondents preferred ERCP for the management of CDL. Having a reliable ERCP proceduralist available, use of selective IOC, and metropolitan status were independently associated with preoperative ERCP. Postoperative ERCP was preferred for managing intraoperatively discovered CDL. Many surgeons are uncomfortable performing LCBDE, and increased training may be needed.

     

Is laparoscopic fiberoptic choledochoscopy for common bile duct stones a fine option or a mandatory step?

Background  

Because choledochoscopy often is a challenging maneuver, it would be advantageous to define the real utility of its use. This study aimed to compare blind exploration of the common bile duct (CBD) with choledochoscopy-assisted CBD stone removal in terms of patient outcome and complication rate.     

Cholecystectomy after endoscopic sphincterotomy for common bile duct stones: is surgery necessary?

It has been more than 30 years since the introduction of endoscopic sphincterotomy for the management of choledocholithiasis. Once introduced, this endoscopic intervention subsequently enabled clinicians to witness the natural history of leaving the gallbladder in situ once the common duct calculi were removed. Because many people were free of symptoms once the common bile duct was cleared of stones, patients and physicians alike soon questioned whether it was necessary to remove the gallbladder at all. Despite more than two decades of clinical research and numerous published reports, the answer to this question remains elusive. Similarly, the management algorithm for choledocholithiasis in patients with an intact gallbladder remains controversial. We review the available key data regarding this question. Importantly, there are only three prospective, randomized trials that have examined the need for cholecystectomy after endoscopic sphincterotomy, with case studies constituting most of the published reports. Consequently, the literature on this topic remains inconclusive, weakened by its retrospective approach, considerable variability between the patients studied, inconsistent inclusion and exclusion criteria, and frequently poor patient follow-up. Nonetheless, the preponderance of data favor removing the gallbladder after endoscopically clearing the common bile duct of gallstones because an estimated 25% of patients will experience recurrent symptoms within a 2-year follow up period. Recognizing the existence of various mitigating clinical factors, we advocate adopting a selective wait-and-see approach for high-risk patients, especially those with a life expectancy of less than 2 years or severely debilitating comorbidities.     

Extended bile duct resection — a new oncological approach to the treatment of central bile duct carcinomas?

Since the results of surgical resection and transplantation in the treatment of central bile duct carcinomas have been poor and neither radiotherapy nor chemotherapy has shown promising results, a new attempt to achieve curative resection has been made to combine liver transplantation with the Kausch-Whipple operation. With this operation the complete biliary system can be resected without touching the region of the hepatoduodenal ligament. Our intention is to avoid tumor cell spread by this no-touch technique. Tumor cell spread is very likely to occur with the commonly used technique of close dissection near the centrally located carcinoma. In the seven patients operated on so far, we observed that the combination of total hepatectomy, partial duodenopancreatectomy and liver transplantation can be performed with fewer postoperative problems than cluster transplantation and probably has the same oncological benefit in terms of more radical resections at least for central biliary carcinomas. Theoretically, the radicalness of the resection should be greater than with liver transplantation or bile duct resection alone. Whether this concept helps to achieve better results in surgical treatment of early Klatskin tumors can only be evaluated after a longer follow-up. So far, six of seven patients have survived the operation without great problems and have been discharged from the hospital. The quality of life after this procedure seems to be better than with total pancreatic resection or even with replacement of the pancreas.

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Die erweiterte resektion des gallenganges — ein neues onkologisches konzept zur behandlung zentraler Gallengangskarzinome. Beschreibung der methode und frühergebnisse

Zusammenfassung Da die bisherigen Ergebnisse der chirurgischen Therapie von Gallengangskarzinomen ungünstig sind und weder Bestrahlung noch Chemotherapie ermutigende Ergebnisse zeigen, wurde in einem neuen Ansatz der Versuch unternommen, durch die Kombination von Lebertransplantation und Operation nach Kausch-Whipple eine kurative Resektion zu erreichen. Bei diesem Verfahren kann das gesamte Gallengangsystem ohne wesentliche Manipulation am Ligamentum hepatoduodenale reseziert werden. Es ist beabsichtigt, bei dieser No-touch-Technik intraoperative Tumorzellaussaat zu verhindern, welche bei der herkömmlichen Technik der Präparation an einem zentral gelegenen Gallengangskarzinom sehr leicht auftreten kann. An den bislang operierten 7 Patienten konnte gezeigt werden, daß die Kombination von Lebertransplantation mit partieller Duodenopankreatektomie weniger postoperative Probleme erzeugt als die sogenannte Clustertransplantation und speziell für Gallengangskarzinome wahrscheinlich denselben onkologischen Vorteil erhöhter Radikalität bietet. Zumindest theoretisch sollte die Radikalität im Vergleich zur alleinigen Transplantation verbessert sein. Ob dieses Konzept bessere Ergebnisse bei der chirurgischen Behandlung früher Klatskin-Tumoren erlaubt, kann erst nach einem längeren Nachbeobachtungszeitraum beurteilt werden. Bis jetzt haben 6 von 7 Patienten die Operation überlebt und konnten nach Hause entlassen werden. Die Lebensqualität scheint nach dieser Operation besser zu sein als nach totaler Pankreatektomie oder nach Pankreastransplantation.

     

How reliable is intraoperative cholangiography as a method for detecting common bile duct stones?

Background  Although intraoperative cholangiography (IOC) is a widely used method for detecting common bile duct stones (CBDS), its accuracy has not been fully evaluated in large nonselected patient samples. The purpose of this study was to assess the sensitivity, specificity and predictive value of dynamic IOC regarding its ability to diagnose CBDS in a population-based setting, and to assess the morbidity associated with the investigation. Methods  All patients operated on for gallstone disease between 2003 and 2005 in the county of Uppsala in Sweden, a county with a population of 302,000 in December 2004, were registered prospectively. The outcome of cholangiography was validated against the postoperative clinical course. Results  1171 patients were registered, and among these IOC was performed in 1117 patients (95%). Common bile duct stones were found in 134 patients (11%). One perforation of the common bile duct caused by the IOC catheter was recorded. Sensitivity was 97%, specificity 99%, negative predictive value 99%, positive predictive value 95%, and overall accuracy 99%. In 7 of the 134 cases where IOC indicated CBDS, no stones could be verified on exploration. In 4 of the 979 cases where IOC was normal, the clinical course indicated overlooked CBDS. Conclusion  Intraoperative cholangiography is a safe and accurate method for detecting common bile duct stones.     

Thirteen years’ experience with laparoscopic transcystic common bile duct exploration for stones

Background The aim of the present study was to evaluate the effectiveness and long-term results of laparoscopic transcystic common bile duct exploration (TC-CBDE). Methods Ductal stones were present in 344 of 3212 patients (10.7%) who underwent laparoscopic cholecystectomy (LC). The procedure was completed laparoscopically in 329 patients (95.6%), with TC-CBDE performed in 191 patients (58.1%) who are the object of this study, or with a transverse choledochotomy in 138 cases (41.9%). Results Biliary drainage was employed in 71 of 191 cases (37.2%). Major complications occurred in 10 patients (5.1%), including retained stones in 6 (3.1%). Mortality was nil. No patients were lost to follow-up (median: 118.0 months; range: 17.6–168 months). No signs of bile stasis, no recurrent ductal stones and no biliary stricture were observed. At present 182 patients are alive with no biliary symptoms; 9 have died from unrelated causes. Conclusions Long-term follow-up after laparoscopic TC-CBDE proved its effectiveness and safety for single-stage management of gallstones and common bile duct stones.     

Why does laparoscopic common bile duct exploration fail?

Laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis carries an overall ductal clearance rate of between 85% and 95%. We present our single institute experience with LCBDE. Between July 1999 and July 2003, 60 patients (42 females, 18 males; median age, 59.5 years) with proven choledocholithiasis underwent LCBDE for common bile duct (CBD) clearance. The method failed to clear the CBD in six patients, resulting in a 90% overall success rate. Conversion to a conventional open approach (n = 1), hand-assisted LCBDE (n = 1), T-tube placement followed by multiple postoperative endoscopic retrograde cholangiopancreatography (ERCP; n = 2), and endobiliary stent placement followed by single successful postoperative ERCP in each case (n = 2) were chosen as treatment options when the laparoscopic method failed to clear the CBD. LCBDE is a feasible and safe method of managing CBD stones. Impacted stones at the lower end of the CBD or in the ampulla of Vater represent the most likely factors leading to failure of LCBDE. Laparoscopic endobiliary stent placement followed by postoperative ERCP represents the most attractive alternative in these difficult cases of impacted stones.     

Study on the role of the activities of β-glucuronidase in the two type of primary cholelithiasis in the common bile duct

目的 探讨内外源性β-葡萄糖醛酸酶在两类原发性胆总管结石(胆固醇结石与胆色素结石)形成中的作用.方法 应用Fishman法检测实验组、对照组胆总管胆汁中内、外源性β-G活性.结果 胆红素结石组(PS)、胆固醇结石组(CHS)与对照组(CG)比较,内、外源性β-G活性及总活性均有显著性差异;胆红素结石组与胆固醇结石组之间比较(手术当天)外源性β-G活性差异有显著性,内源性β-G活性差异无显著性.(2)实验组手术当天胆汁中内源性β-G活性与术后第七日的比较差异无显著性;而外源性β-G活性手术前、后比较差异有显著性.结论 内、外源性β-G可能是这两类原发性胆总管结石形成与再发的基本原因之一.