Endoscopic retrograde cholangiopancreatography in the management of choledocholithiasis

Surgeons today have a wide range of therapeutic options for the management of patients with choledocholithiasis. Endoscopists, interventional radiologists, and surgeons employ a variety of techniques to access and remove common bile duct stones (CBDS) successfully. Although earlier studies have been done to assess the relative merits of laparoscopic and endoscopic management of CBDS, few of them have employed a randomized prospective trial for the comparison. Without recognized parameters for comparison, no definitive conclusions can be drawn. Herein, we examine the role of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) as an important adjunct to laparoscopic cholecystectomy (LC) in the management of CBDS. The three main scenarios in which this modality is employed for CBDS removal are selective preoperative ERCP, intraoperative ERCP, and postoperative ERCP. We conclude that an appropriate balance must be struck to maintain a high yield of positive or therapeutic ERCP, avoid unnecessary ERCP, and not miss CBDS, while ensuring acceptably low rates of morbidity and mortality and controlling costs. As we await the publication of prospective data, we may look for direction from decision analysis in order to develop optimal management strategies and define the ``best practice' results that should be expected of operators before new procedures and innovative technology are accepted on a widespread basis. Received: 21 July 1999/Accepted: 10 September 1999     

Endoscopic sphincterotomy for the treatment of gallstone pancreatitis during pregnancy

Background: Gallstones are the most common cause of acute pancreatitis during pregnancy. Without intervention, gallstone pancreatitis during pregnancy is associated with an antepartum recurrence rate of 70%, which exposes the mother and fetus to an increased risk of morbidity and mortality. A safe, effective means to prevent recurrent gallstone pancreatitis during pregnancy is desirable. Methods: Since 1991, we have managed gallstone pancreatitis in three pregnant patients with endoscopic retrograde cholangiogram (ERC), followed by spincterotomy, despite the absence of common bile duct stones. Results: All patients were judged to have mild pancreatitis by modified Ranson criteria and the Multiorgan System Failure criteria. During cholangiogram, fetal shielding was employed and fluoroscopy times ranged from 36 s to 7.2 min. One patient experienced postprocedure pancreatitis of 48-h duration. None of the patients experienced further episodes of pancreatitis and none underwent predelivery cholecystectomy. Conclusions: In pregnancy-associated gallstone pancreatitis, endoscopic sphincterotomy prevents recurrence of pancreatitis and the need for cholecystectomy during gestation. We believe endoscopic sphincterotomy represents a promising management alternative for gallstone pancreatitis during pregnancy. Further investigation is warranted. Received: 30 December 1996/Accepted: 12 September 1997     

Endoscopic treatment of a choledochocele in a 2-year-old child

Choledochocele is an extremely rare congenital lesion of the biliary tree causing abdominal pain, pancreatitis, and obstructive cholestasis. Traditionally the therapy for this malformation has been surgery. Recently endoscopic therapy has been utilized alternatively for the treatment of choledocele in adults. We report the case of a 2-year-old girl with a choledochocele who was treated by endoscopic sphincterotomy and placement of a biliary stent. The prosthesis was removed after 4 months. After a follow-up of 20 months the patient remains free of symptoms. Our experience suggests that endoscopic treatment of congenital biliary disease can be performed accurately. Further studies will be necessary to confirm the value of stent implantation in congenital bile duct stenosis. Received: 7 June 1995/Accepted: 22 January 1996     

Endoscopic treatment of distal bile duct stricture from chronic pancreatitis

Background: Endoscopic placement of biliary stents is an effective initial treatment for jaundice and cholangitis caused by common bile duct (CBD) strictures secondary to chronic pancreatitis; however, the role of endoscopic treatment for long-term management of these strictures is less clear. In 1992, we designed a protocol of balloon dilatation and stenting for ≥12 months. This study evaluates endoscopic therapy as a definitive long-term treatment for these strictures. We have treated 25 patients with this protocol. Methods: All patients had an endoscopic sphincterotomy, balloon dilatation of the stricture, and then placement of a polyethylene stent (7–11.5 F). Stents were exchanged at 3–4-month intervals to avoid the complications of clogging and cholangitis. We were particularly interested in how many patients would achieve resolution of the stricture and tolerate removal of the stent. Results: The length of the CBD strictures ranged from 8 to 40 mm. Within days of stenting, all patients achieved relief of jaundice and cholestasis. Complications consisted of six episodes of cholangitis and nine episodes of pancreatitis. There were no deaths. Twenty of the 25 patients are now stent-free after an average stenting period of 13 months (range, 3–28). To date, there has been no recurrence of stricture, for a mean of 32 months. Three patients still have stents in place, and two patients required operation—one for persistent stricture and recurrent cholangitis after 8 months of stenting, and one for a mass in the head of the pancreas that was thought to be cancer. Conclusions: Our results indicate that these strictures will respond and dilate after a course of stenting in 80% of patients, with an acceptable morbidity. Although these are medium-term results at 32 months, we would expect most recurrences within the 1st year following stent removal. In some cases, stenting is necessary for >12 months. Thus, the data suggest that endoscopic stenting provides definitive treatment in most patients with CBD stricture due to chronic pancreatitis and may be considered a viable alternative to standard surgical bypass. Received: 18 May 1999/Accepted: 24 September 1999     

Endoscopic endocrine surgery in the neck

Background: The fervor surrounding minimally invasive surgery, which began with laparoscopic cholecystectomy in the late 1980s, has spread to nearly all surgical specialties. Methods: After experimental success in an animal model, we recently performed our first case of endoscopic subtotal parathyroidectomy in a 37-year-old man. The patient, who had a history of severe pancreatitis and pancreatic calculi, was diagnosed as having hyperparathyroidism. The option of endoscopic parathyroidectomy was proposed and accepted. After placing the first trocar directly under the platysma, a space was created by bluntly dissecting with the tip of a 5-mm endoscopic camera. Four parathyroid glands were identified, and after a frozen-section diagnosis of parathyroid hyperplasia, three-and-one-half of the glands were resected. Results: The patient developed slight hypercarbia and subcutaneous emphysema during the procedure, but no other problems were noted. His postoperative course was otherwise unremarkable. Conclusions: This is the first case reported of an endoscopic parathyroidectomy. This experience makes us optimistic about the future of endoscopic neck surgery. Received: 3 April 1997/Accepted: 6 August 1997     

Endoscopic intrauterine surgery in primates

Current protocols for fetal surgery require cesarean section and partial fetal extraction, both of which impart significant risks to the mother and fetus. Endoscopic fetal surgery is less invasive and will likely reduce some of these risks, but the technical difficulties and feasibility in a primate model have yet to be explored fully. Four pregnant baboons (95 days gestation) were anesthetized, their uteruses exposed via an abdominal incision, and blunt-tipped flanged endoscopic ports inserted. Amniotic fluid was removed, and warmed saline was infused to dilate the uterus. To evaluate instrumentation and wound closure, the tip of the snout was externalized and bilateral cleft lip-like defects made. The lips were then endoscopically repaired by suture (Endostitch, U.S. Surgical) or unique nonpenetrating clips (VCS, U.S. Surgical). The saline was then removed, amniotic fluid returned, and the ports carefully removed. After 4 weeks, the fetuses were delivered and evaluated. Eight cleft lip-like defects were successfully repaired in all four cases. Operative time averaged 83 min. No infections, amniotic leaks, or adhesions developed. Survival was 50% with two fetuses delivering within 48 hours postoperatively: one from preterm labor, the other with fetal demise from retroperitoneal hemorrhage after operative blunt abdominal trauma. We demonstrate the feasibility of endoscopic fetal surgery in primates. The use of blunt-tipped flanged ports provides a fluid tight seal and allows appropriate closure of the fetal membranes, but requires laparotomy and uterine exposure. Distension of the uterus with warmed saline affords a larger operating field, enhancing visualization and instrumentation of the fetus. Grasping the fetus through the exposed uterus gives excellent control for repair. However, such control is also needed in a percutaneous approach. Further instrumentation development is needed to accomplish similar control for the percutaneous approach. Received: 28 April 1997/Accepted: 18 February 1998     

Evaluation of laparoscopic management of common bile duct stones in 220 patients

Background: The aim of this study was to evaluate the feasability and results of laparoscopic management of common bile duct stones (CBDS). Methods: From October 1990 to November 1996, 220 patients with CBDS have been managed laparoscopically. CBDS were suspected or diagnosed preoperatively in 130 patients (59.1%) and at intraoperative cholangiography (IOC) in 90 patients (40.9%). A transcystic duct extraction (TCDE) was attempted in 112 patients and a primary choledochotomy in 108 patients. Results: TCDE was successful in 77 cases (68.8%). The 35 failures were treated by 29 laparoscopic choledochotomies, 1 intraoperative and 5 postoperative endoscopic sphincterotomies (ES). A choledochotomy was thus performed in 137 cases and was successful in 133 cases (97.1%). The four failures were managed by three laparotomies and one postoperative ES. The overall success rate was 95.5% (210/220). There was 4 deaths (0.9%) within the 1^st postoperative month in ASA 3 patients and the morbidity rate was 9.1% (20/220). There were 7 residual stones (3.2%). Conclusions: Laparoscopic desobstruction of CBDS appears to be safe and effective and has the advantage to be a single-stage procedure. It could become in the future with refinement of instrumentation and skill of surgeons the best treatment for the majority of patients harboring CBDS. Received: 8 December 1996/Accepted: 14 February 1997     

A stratified intraoperative surgical strategy is mandatory during laparoscopic common bile duct exploration for common bile duct stones

Background: Open exploration and endoscopic sphincterotomy (ES) remain the preferred treatment of common bile duct stones (CBDS). The recent spread of laparoscopy has worsened the dilemna of choosing between surgical and endoscopic treatment of CBDS. The aim of this study was to critically evaluate the results of our preliminary experience with laparoscopic common bile duct exploration (CBDE) for CBDS. Methods: Ninety-two consecutive patients were prospectively submitted to laparoscopic CBDE. Surgical strategy included an initial transcystic approach or laparoscopic choledochotomy. Failure of stone clearance was managed by conversion to open CBDE or by postoperative ES. Electrohydraulic lithotripsy and papillary balloon dilatation were selectively used. Stone clearance was assessed by choledochoscopy and control cholangiography. Results: The overall laparoscopic stone clearance in this series was 84% (transcystic route 63% and choledochotomy 93%). Conversion to laparotomy was mandatory in 12% of the patients because of incomplete stone clearance and in 5% because of intraoperative complications. Postoperative ES was required in 4% of the patients, giving an overall surgical success rate of 96%. When indicated (small and limited number of stones located below the cysticocholedochal junction, with a dilated and patent cystic duct) the transcystic route had the lower success rate, the higher complication rate, and the shorter operative time and postoperative hospital stay. When indicated (accessible and dilated common bile duct over 7 mm), laparoscopic choledochotomy had the higher success rate, the lower complication rate, the longer operative time, and the longer postoperative hospital stay, which is related to associated external biliary drainage. The hospital mortality included two high-risk patients (2%) and the complications rate was 15%. Conclusions: Laparoscopic CBDE is safe in selected patients. A stratified intraoperative surgical strategy is mandatory in deciding between a transcystic route and choledochotomy with specific indications for each approach. When feasible, laparoscopic choledochotomy is more efficient and safe than the transcystic route, but it is associated with a longer postoperative hospital stay, which is due to external biliary drainage. Received: 7 May 1996/Accepted: 19 November 1996     

Experience with percutaneous transhepatic cholangioscopy (PTCS) in the management of biliary tract disease

Background: Biliary tract disorders often present significant management difficulties, particularly in patients who are poor surgical candidates. Percutaneous transhepatic cholangioscopy (PTCS) is an infrequently utilized alternative that might offer significant therapeutic benefit. We reviewed our experience with the use of this modality as a definitive therapy for biliary tract disorders. Methods: Patient records at the Atlanta VAMC and Emory University hospitals were reviewed. We identified 17 patients who had undergone 25 PTCS interventions between August 1994 and December 1998. The indications for PTCS included dilatation of biliary-enteric anastomoses in four patients, biliary stone removal (with or without lithotripsy) in eight patients, stricturoplasty in four patients, biopsy of suspected biliary neoplasms in seven patients, and removal of obstructing clot in one patient. Most procedures (n= 17) were performed through percutaneous transhepatic tracts (12–18 Fr) that were <1 week old. All tracts were dilated to operating size on the day of the procedure. All patients received periprocedural antibiotics. Results: The interventions were successful in seven of eight stone removals, four of five stricturoplasties, three of four anastomotic dilatations, seven of seven biopsies, and the single clot removal. The only complication involved one episode of hemobilia, requiring angio-embolization of a small branch of the right hepatic artery. Conclusions: PTCS is a safe, useful, and well-tolerated adjunct to the more common endoscopic and surgical techniques for managing complicated biliary tract disorders. Our experience suggests that PTCS can be performed early, without prolonged sequential dilatation of the percutaneous transhepatic tract, and may allow avoidance of operation in high-risk surgical candidates. Received: 1 April 1999/Accepted: 2 July 1999     

Laparoscopic cholecystectomy and interventional endoscopy for gallstone complications during pregnancy

Background: Symptomatic or complicated gallstone disease is the most common reason for nongynecological operations during pregnancy. Gallstones are present in 12% of all pregnancies, and more than one-third of patients fail medical treatment and therefore require surgical endoscopy or laparoscopy. Gallstone pancreatitis and jaundice during pregnancy is associated with a high recurrence rate, exposing both fetus and mother to an increased risk of morbidity and mortality. Methods: During a 4-year period, all pregnant patients (n= 37) with symptomatic or complicated gallstone disease were studied prospectively at the Landeskrankenhaus in Salzburg, Austria. Five patients had an endoscopic retrograde cholangiopancreatogram (ERCP) for biliary pancreatitis or jaundice; two of these underwent subsequent laparoscopic cholecystectomy. Another seven patients required laparoscopic cholecystectomy for severe pain or cholecystitis; all were in their 13th–32nd gestational week. Access was established by Veress needle in all cases. Insufflation pressure was 8–10 mmHg, and mean operative time was 62 min. Results: All patients delivered full-term, healthy babies. There were no postendoscopic or postoperative complications. All patients enjoyed full relief from their symptoms; there were no recurrences of pancreatitis or jaundice. Conclusions: The combination of ERCP and laparoscopic cholecystectomy offers a safe and effective option for the definitive treatment of complicated gallstone disease and intractable pain during pregnancy, and there is sufficient access for the combined treatment to be employed. Received: 7 September 1998/Accepted: 2 June 1999     

Endoscopic use of fibrin adhesives

When used endoscopically fibrin adhesives are injected through twin-lumen catheters, which can reach up to 180 cm in length. Because fibrinogen solutions have a high viscosity, significant delivery forces are necessary, resulting in discomfort for the operator. Therefore, the two predominant fibrin sealants were characterized with respect to their viscosity and the force needed for their injection. Viscosity was determined at 18°C, 25°C, and 37°C in a micro-Ostwald viscosimeter. Additionally, the maximum forces needed for injection through a 27-cm and a 160-cm catheter were determined at 25°C in an Instron materials testing machine. Compared with preparation A the viscosity of preparation B was 8.0–34.5 times higher at 18°C, 4.6–13.8 times higher at 25°C and 3.1–6.4 times higher at 37°C. In consequence, the delivery forces were 1.5–2.5 times (27 cm probe) and 3.4–4.5 times (160 cm probe) the values determined for preparation A. For preparation B a maximum load of 3.8 kg was necessary for injection. Assuming that different adhesive preparations have the same effect, a preparation of lower viscosity seems to be more suitable for use via long catheters than a preparation of high viscosity. Received: 1 May 1998/Accepted: 28 May 1998     

Endoscopic axillary exploration and sentinel lymphadenectomy

Background: Minimally invasive approaches have changed the practice of surgery in several specialties. The purpose of this study was to develop a reproducible endoscopic technique for the evaluation of the axilla in breast cancer patients. Methods: A total of 23 patients with biopsy-proven breast carcinoma were enrolled. Patients were positioned in the supine position with the ipsilateral arm abducted at 90°. A 1-cm skin incision was made at the superior aspect of the axilla. Dissection was carried bluntly to the lateral border of the pectoralis major. A balloon distention device was inserted into the tract and distended under endoscopic vision to create a working space. Insufflation was initiated up to a pressure of 8 mmHg. A 30° laparoscope was introduced for visualization of axillary contents. One or two additional 5-mm cannulas were placed as needed under direct visualization. Manipulation of axillary contents was performed, and in 19 patients a sentinel node identification technique was applied. Results: In all patients, using insufflation and minimal instrument dissection, the axillary vein, long thoracic, and thoracodorsal nerves were found in their usual anatomical locations. Utilizing blunt and sharp dissection, the axilla was thoroughly inspected, and individual lymph nodes were easily identified and extracted. In 11 of 19 patients, a sentinel node or blue dye was identified using isosulfan blue. There was a procedure concordance of 84%, and there were no complications. Conclusions: We describe a novel endoscopic technique for the evaluation of the axilla in breast cancer patients. This technique allows (a) creation of a minimally invasive working space within the axilla, (b) recognition of key axillary anatomic landmarks, and (c) instrument manipulation within the axilla to identify and extract lymph nodes, and apply the sentinel node technique. This is the first report of a minimally invasive approach to axillary exploration to employ sentinel lymph node mapping. Received: 22 April 1996/Accepted: 15 May 1998     

Video-assisted thoracoscopic surgery in the management of loculated empyema

Background: Fibropurulent empyema (stage II of Light) does not respond to antibiotic therapy and simple drainage. If the condition is inadequately treated, restrictive pulmonary deficit develops, necessitating thoracotomy and decortication. We report our experience with the videoscopic management of stage II and limited stage III disease. Methods: Ten consecutive patients underwent videoscopic debridement of fibropurulent empyema; three of them required removal of limited visceral and parietal rind. Results: The mean operating time was 42 ± 8.1 min. Postoperative pyrexia and leucocytosis settled within 4.2 ± 2.1 days and 13.1 ± 3.2 days, respectively. Intercostal chest tubes were removed by 4.5 ± 1.0 days. The mean fall in hematocrit following surgery was 4.9%. Parenteral analgesics were required for 1.0 ± 0.5 days and oral analgesics for 3 ± 1.6 days. The mean postoperative stay was 11 ± 8.1 days. No patient required any further intervention. Conclusions: Videoscopic debridement of empyema produces excellent results, with minimal patient morbidity and a short hospital stay. We recommend it as the preferred method for first-line management of fibropurulent (stage II) empyema. Received: 10 December 1998/Accepted: 13 May 1999     

Multicentric experience of the Belgian Group for Endoscopic Surgery (BGES) with endoscopic adrenalectomy

Background: Adrenalectomy is not a frequent operation. Therefore the newly developed laparoscopic approach is sporadically performed by surgeons dealing with endocrine disorders. Methods: Some 54 videoendoscopic adrenalectomies performed on 52 patients by five surgical teams between October 1993 and December 1996 were prospectively evaluated. Results: Indications for endoscopic adrenalectomy were pheochromocytoma (n= 17), primary hyperaldosteronism (n= 15), Cushing's adenoma or disease (n= 7), nonsecreting adenoma (n= 7), single metastasis from adenocarcinoma (n= 2), adenoma with dehydroepiandrostenedione (DHEAS) hypersecretion (n= 3), and ACTH-secreting metastases from a thymoma (n= 1). Of the 54 adrenalectomies performed, 31 were of the left gland, 19 of the right and two bilateral. Laparoscopic adrenalectomy was successful in 50 patients (96%). Median tumor size was 4 cm (range 1.5–12), median operation duration was 80 min (range 59–360), and median postoperative stay was 4 days (range 2–13). One patient required blood transfusion. Conclusions: Endoscopic adrenalectomy can safely be performed—even sporadically—by surgeons well versed in adrenalectomy techniques for endocrine disorders and trained in endoscopic surgery. Received: 25 March 1997/Accepted: 16 May 1997     

Endoscopic grading of the gastroesophageal valve in patients with symptoms of gastroesophageal reflux disease (GERD)

Background: It has been suggested that endoscopic grading of the gastroesophageal flap valve is a good predictor of the reflux status. Methods: To test this hypothesis, 268 symptomatic patients underwent endoscopic grading of the gastroesophageal valve using Hill's classification, with grades I through IV. Esophageal acid exposure, lower esophageal sphincter characteristics, and the degree of esophageal mucosal injury were compared among the groups. Results: The prevalence of a mechanically defective sphincter, abnormal esophageal acid exposure, erosive esophagitis, and Barrett's esophagus increased with increasing alteration of the gastroesophageal valve. The presence of a grade IV valve indicated increased esophageal acid exposure in 75% of patients. As a predictor, this is similar to lower esophageal sphincter pressure but not as good as the presence of esophageal mucosal injury. Conclusions: Endoscopic grading of the gastroesophageal valve provides useful information about the reflux status but is less useful as an indicator of gastroesophageal reflux disease (GERD) than the presence of esophageal mucosal injury. Received: 28 April 1999/Accepted: 23 June 1999     

Endoscopic resection for submucosally invasive colorectal cancer

Background: Recent advances in colonoscopy have resulted in an increasing number of endoscopic resections of colorectal neoplasms. However, endoscopic resection of submucosal invasive cancer remains a controversial issue. Methods: The subjects for this study were the surgically treated patients with submucosal invasive colorectal cancer. These patients were classified into two groups: those with versus those without preoperative endoscopic resection. Clinicopathologic features and prognosis were compared and analyzed. Results: Fifty patients underwent surgery for submucosally invasive colorectal cancer. Numbers of patients with and without preoperative endoscopic resection were 22 and 28, respectively. In 36.4% of the patients, endoscopic resections were incomplete. Two patients in whom the preoperative endoscopic resections had revealed a positive cancer margin, had nodal metastasis. One of these patients also developed hepatic metastasis. Endoscopic findings such as diameter and shape were not indicative of either lymphatic or vascular invasion. There were no morbidities or mortalities associated with endoscopic resection or surgery. Conclusions: Preoperative endoscopic resection for colorectal submucosal cancer is feasible, provided the resection is complete. The indications for surgical treatment should be determined after pathologic examination. Received: 30 December 1997/Accepted: 13 April 1998     

Endoscopic stapling diverticulostomy for Zenker's diverticulum

Endoscopic stapling diverticulostomy (ESD) using an endostapler is a modification of the standard endoscopic treatment of Zenker's diverticulum (ZD). It is characterized by complete myotomy of the upper esophageal sphincter, with division of the common wall between diverticulum and esophagus, followed by immediate simultaneous closure of the divided edges with the staples. ESD was performed on 21 patients with ZD between January 1996 and October 1997. The results were then evaluated. Operation time averaged 22 min. Wide opening of the diverticulum and excellent hemostasis were achieved. All of the patients but one, who died postoperatively of myocardial infarction, resumed oral intake without any evidence of cervical sepsis or mediastinitis. Complete relief of dysphagia was achieved in all 20 patients. Hospital stay averaged 4.7 days (range, 2–7 days). The patients were followed up after ESD for a median time period of 12 months. No relapses were recorded. ESD is an effective endoscopic treatment for ZD that entails a low risk of complications and requires only a short period of hospitalization. Received: 9 March 1998/Accepted: 22 June 1998     

Current status of extracorporeal shock wave lithotripsy

Summary Extracorporeal shock wave lithotripsy (ESWL) is standard therapy for urolithiasis. With comparable technical principles, various lithotripters have been developed and are in routine use. Renal pelvic stones, calyceal stones, ureteral stones, and other special forms can be treated with varying results. Currently, the so-called clinically insignificant residual fragments and the recurrence of calculi are under discussion. Whereas the side effects of ESWL are well known, studies comparing ESWL with other endourological procedures are still lacking.      

Recurrent pancreatitis in a child with pancreas divisum

Pancreas divisum is a rare congenital anomaly of the pancreatic ducts that has been implicated in pancreatitis. In addition, the finding of a Santorinicele, which is a cystic dilatation of the dorsal duct, suggests that there is an obstruction associated with a congenital or acquired weakness of the mucosa. We used an endoscopic technique to treat a child with recurrent pancreatitis who was found to have pancreas divisum and a large Santorinicele. Received: 2 September 1998/Accepted: 13 October 1998     

Laparoscopic choledochotomy with primary closure

Background: Thirty-three patients were candidates for laparoscopic choledochotomy. The indications for this operation are described. Methods: The procedure was completed 32 times (97%). We had 29 successful common bile duct (CBD) clearances, three negative explorations, and one failed clearance which needed to be converted to laparotomy. All the completed procedures ended with primary closure of the main duct. Median duration of surgery was 180 min (range 100–300), including three associated laparoscopic procedures. Results: There were three postoperative complications (9.4%), none major. Average postoperative hospital stay was 7.1 days (range 4–14). In May–June 1995 we controlled 31 out of the 32 consecutive patients (one patient was lost to follow-up) who had a successful laparoscopic choledochotomy from October 1991 to December 1994. Median follow-up was 22 months (range 5–44). Besides clinical control, 23 patients also had ultrasound (US) controls and 24 had blood tests. Eleven had intravenous cholangiotomography. Two patients died 11 and 22 months after the operation for unrelated causes and without biliary symptoms. Two patients had umbilical hernias. One had a small residual asymptomatic stone, which was removed endoscopically. None had signs of postoperative CBD stricture. At US, CBD was ≤7 mm in 15 patients, 8–10 mm in four patients, and 10–12 mm in three patients. The last group had preoperative CBD dilation, too. We could compare preoperative and postoperative CBD diameters in 22 patients: 11 had no change; in nine it decreased; and two had a slight increase (8–10 mm). Conclusions: We conclude that laparoscopic choledochotomy with primary closure is a very good operation: It has a high success rate and low morbidity. Mortality is nil so far. Medium-term results are very positive: We had no CBD stricture and only one case of asymptomatic residual stone, which could have been avoided. Our results suggest that intraductal biliary drainage is useless, and its specific complications are well known. Received: 20 October 1995/Accepted: 28 February 1996