经胆囊管腹腔镜胆道探查术治疗胆总管结石的临床研究

目的:比较分析腹腔镜下经胆囊管和经胆总管切开T管引流两种方法胆道镜取石治疗胆囊结石继发胆总管结石的疗效,以评价经胆囊管腹腔镜胆道探查术治疗胆总管结石的临床价值。方法:2001年3月至2003年3月按胆道探查途径不同将28例胆石症患者分为胆囊管组(n=8)和胆总管切开组(n=20)。患者经B超和术中胆道造影或加内窥镜逆行胆管造影(ERC)确诊。观察两组病例的术后肛门排气时间、腹腔引流时间、术后住院日、住院费用及手术并发症的发生情况,术后对患者进行全程跟踪随访。结果:胆总管切开组肛门排气时间、腹腔引流时间、术后住院日、住院费用明显长于或高于胆囊管组(P>0.05)。胆囊管组发生手术并发症1例(12.5%);胆总管切开组5例(25.0%),其中胆道并发症4例(20.0%),需要再次微创处理2例(10.0%),需再次手术治疗的严重并发症2例(10.0%);手术并发症发生率胆总管切开组明显高于胆囊管组(P<0.05)。随访两组患者均无胆管狭窄、急性胆管炎及急性胰腺炎发生和结石复发。结论:经胆囊管途径的腹腔镜胆道探查术充分体现了微创外科技术的优点,适于胆囊结石继发胆总管结石患者,其疗效优于胆总管切开T管引流途径的腹腔镜胆道探查术。     

Observations on the function of Oddi's sphincter in patients with primary bile duct stones

We recorded the pressure of Oddi's sphincter (SO) in 54 patients with gall stones and 25 patients as controls who had no biliary disease. Endoscopic manometry used in this study recorded the dynamic changes of the intraluminal pressure of SO as well as the static pressure of the common bile duct. It was found that in control group, common bile duct pressure was 1.54 +/- 0.15 kPa, basic pressure of SO 2.12 +/- 0.22 kPa, SO-bile duct pressure difference 0.58 +/- 0.07 kPa, and SO peak pressure 5.56 +/- 0.47 kPa, respectively. There was no significant difference between patients with gallbladder stones and secondary cholelithiasis and those in control group. But the pressure of SO was significantly lower in patients with primary bile duct stones than that in controls. This phenomenon indicates that in such patients the contraction strength of SO is weak or lost. This may explain retrograde cholangitis often seen in some patients. We suggest that in order to prevent retrograde cholangitis, adequate procedure should be taken in operation on patients with functional impairment of SO.     

胆管结石诱发急性重症胆管炎的危险因素分析

目的探讨胆管结石诱发急性化脓性胆管炎的临床危险因素。方法回顾性分析钦州市第二人民医院1998年6月—2009年3月诊治的436例胆管结石患者的临床资料,根据术前检查和术中探查,分为合并ACS组(74例)和非ACS组(362例),用单因素和多因素回归分析方法分析两组的年龄、性别、肝功能、合并胆囊结石、胆囊切除史、胆管结石的数量、胆管结石的直径、梗阻部位、胆管直径、胆管炎病史、胆道手术史、合并糖尿病、合并心血管疾病、合并呼吸疾病等14个因素与ACS的相关性,从而得出胆管结石诱发ACS的相关危险因素。结果 436例患者中有74例并发ACS,占16.97%。单因素分析表明,年龄、肝功能、梗阻部位、胆管炎病史、胆道手术史、合并糖尿病是胆管结石诱发ACS的危险因素。多因素分析表明,年龄、胆道手术史、合并糖尿病是胆管结石诱发ACS的独立因素。结论年龄、胆管手术史、合并糖尿病是胆管结石诱发ACS的最主要危险因素。了解胆管结石诱发ACS的危险因素对临床治疗胆管结石和预防ACS具有指导意义。     

腔镜胆总管切开取石与内镜乳头括约肌切开取石术的远期疗效比较

目的 探讨腹腔镜胆总管切开取石术(laparoscopic common bile duct exploration,LCBDE)治疗胆总管结石的优越性.方法 回顾分析2001年6月至2006年6月间,在贵港市人民医院及广西壮族自治区人民医院微创中心行微创手术治疗的胆总管结石的临床资料.按手术方式不同分两组,即LCBDE组和EST(内镜乳头括约肌切开取石术,endoscopic sphincterotomy)组,比较两组的远期疗效.结果 该组225例,其中LCBDE 106例,EST 119例.术后随访1～6年,平均(3.2±0.8)年.LCBDE组结石复发率为3.77%(4/106),反流性胆管炎的发生率为2.83%(3/106),无乳头狭窄;EST组结石复发率为11.76%(14/119),乳头狭窄的发生率为7.56%(9/119),反流性胆管炎的发生率为12.61%(15/119).全组病例无胆管癌发生.术后结石复发率、乳头狭窄和反流性胆管炎的发生率在两组间的差别均有统计学意义.结论 在治疗胆总管结石方面,LCBDE的远期疗效优于EST.     

腹腔镜下经胆囊管胆总管探查术与胆总管探查并一期缝合术治疗胆总管结石的对比研究

目的:比较腹腔镜下经胆囊管胆总管探查术(LTCBDE)与经胆总管探查(LCBDE)+胆道一期缝合术治疗胆总管结石的效果。方法:回顾性分析2013年1月—2015年12月期间应用微创手术治疗的104例胆总管结石的患者临床资料,其中50例行LTCBDE(LTCBDE组)与54例行LCBDE+胆道一期缝合术(LCBDE+一期缝合组),比较两组的相关临床指标。结果:与LCBDE+一期缝合组比较,LTCBDE组手术时间(91.7 min vs.110.9 min)、术中出血量(15.5 mL vs.17.4 mL)、术后引流量(28.4 mL vs.44.6 mL)、带管时间(7.8 d vs.9.7 d)、住院时间(8.8d vs.10.6d)均明显减少(均P0.05);LTCBDE组术后胆汁漏的发生率明显低于LCBDE+一期缝合组(2.0%vs.13.0%,P=0.036),其他并发症的发生率两组无统计学差异(均P0.05)。结论:LTCBDE治疗胆总管结石安全可靠的,且较LCBDE+胆道一期缝合术更符合微创的目的,在两种术式的适应证均满足的情况下,可优先考虑。     

腹腔镜与开腹胆总管探查术144例对比研究

目的 探讨胆囊结石合并胆总管结石行胆总管探查术的术式选择。方法 回顾性分析144例胆囊结石合并胆总管结石患者行腹腔镜与开腹胆总管探查术的临床资料。根据手术方式分为腔镜组（n=78）和开腹组（n=66）。结果 腔镜组一期缝合39例,T管引流32例,经胆囊管探查2例,中转开腹5例;术后胆漏7例,胆管炎4例,残余结石2例,肠穿孔1例,MODS 1例,电解质紊乱5例,伤口感染2例。开腹组术后胆漏合并胸、腹腔积液1例,胆管炎1例,残余结石2例,术后出血再次手术1例,电解质紊乱4例,伤口感染4例,肝肾功能不全2例,死亡1例。两组在术后并发症发生率方面比较差别无统计学意义（P＞0.05）。结论 与开腹手术比较,腹腔镜胆总管探查取石术具有微创、术中失血少、术后恢复快、术后住院时间短等优点,但尚不能完全替代传统开腹手术。     

Management of common bile duct stones

Background: Common bile duct stones are still a frequent problem. Although new diagnostic and therapeutic techniques are continually being development, they remain poorly defined. Therefore, we decided to evaluate our standard method of diagnosing and treating common bile duct stones. The aim of the study was to determine the short- and long-term results of this method. Methods: Between 1985 and 1995, 552 consecutive patients (200 men and 352 women; median age, 69 years) underwent endoscopic retrograde cholangiography (ERC) because of suspected common bile duct stones. If stones were detected, they were treated endoscopically, if possible. The results and complications of this policy were recorded. Patients were followed 1–13 years after undergoing ERC and endoscopic sphincterotomy (ES). Long-term results and complications during this period were also recorded. Results: ERC was attempted in 552 patients and succeeded in 510 patients (92%): ES was attempted in 315 patients and failed in five (98%). Duct clearance was done in 271 patients; in 26 of these patients, symptoms disappeared spontaneously. Ten patients underwent common bile duct exploration. Complications occurred in 46 patients (8.3%). Mortality was 0.4%, hemorrhage occurred in 3.6%, pancreatitis in 1.4%, sepsis and cholangitis also in 1.4%, and the lithotripter basket became impacted in four patients (0.8%), necessitating to common bile duct exploration. During follow-up, 45 patients (8%) returned, 35 with recurrent stones, five with cholangitis, two with stenosis of the papilla of Vater, and one with biliary pancreatitis. In 35 cases, complications were treated endoscopically, common bile duct exploration was performed in five cases, and symptoms disappeared spontaneously in five cases. Conclusions: ERC is a safe and reliable way of diagnosing common bile duct stones, and ES is a very efficient way of treating them. Morbidity and mortality are low, and the long-term results are very good.     

Association of peripapillary fistula with common bile duct stones and cholangitis

Background: Peripapillary choledochoduodenal fistula (PCDF) is occasionally detected during endoscopic retrograde cholangiopancreatography. Cholelithiasis and biliary bougienage are two suspected causes of PCDF. Methods: The medical records for 841 patients who underwent endoscopic retrograde cholangiopancreatography between 1993 and 2002 were reviewed for evaluation of PCDF. Results: A total of 327 patients had common bile duct stones, and 16 of these had a PCDF at the papilla of Vater. None of the 16 patients had a history of pancreatitis, duodenal ulcer, or had undergone endoscopic retrograde cholangiopancreatography previously. Seven of the 16 had not undergone biliary surgery. Conclusions: This study indicates that PCDF is a relatively common complication of common bile duct stones and cholangitis. According to the present results, PCDF is more frequently associated with common bile duct stones than with biliary surgery and bougienage.     

微创外科治疗胆总管结石的策略探讨

目的 探讨微创外科治疗胆总管结石(CBDS)的策略.方法 回顾性分析2001年6月至2007年1月304例CBDS患者的临床资料.按手术方式不同分三组:十二指肠镜下乳头气囊扩张术加LC组(EPBD组)、十二指肠镜下乳头括约肌切开取石术加LC组(EST组)、腹腔镜联合纤维胆道镜胆总管切开探查术加LC组(LCBDE组).结果 304例中EPBD组35例,EST组138例,LCBDE组131例.三组的手术成功率、近期并发症发生率、残石率比较,差异无统计学意义(x2值分别为1.93、0.038和0.427,P>0.05);手术时间比较差异有统计学意义(F=17.941,P=0.000),LCBDE组优于另两组(EPBD-EST:P=0.122,EST-LCBDE:P=0.000,EPBD-LCBDE:P=0.020);住院时间相比差异有统计学意义(F=24.016,P=0.000),其中EPBD组最短(EPBD-EST:P=0.000,EST-LCBDE:P=0.198,EPBD-LCBDE:P=0.000).远期并发症:EPBD组结石复发2例(6.7%),胆管炎1例(3.3%),无乳头狭窄;LCBDE组结石复发7例(6.0%),胆管炎3例(2.6%),无乳头狭窄;EST组结石复发18例(15.8%)、乳头狭窄9例(7.9%)、胆管炎14例(12.3%);比较三组结石复发、胆管炎、乳头狭窄的发生率,差异有统计学意义(x2值分别为6.482、9.160和12.02,P<0.05),EST组高于EPBD组和LCBDE组.结论 有适应证的胆总管结石可首选EPBD治疗,失败或无适应证者则选择LCBDE,EST仅适用于有严格适应证者.     

Endoscopic management of common bile duct stones leaving the gallbladder in situ. A cohort study with long-term follow-up

BACKGROUND: Obstructive jaundice caused by stones is a common disorder, mostly managed by endoscopic sphincterotomy followed by cholecystectomy. The aim of this study was to evaluate whether or not clearance of the common bile duct alone is sufficient as treatment for patients with choledocholithiasis. METHODS: A cohort with 447 patients with symptomatic cholecystocholedocholithiasis, undergoing endoscopic retrograde cholangiography (ERC) and if necessary sphincterotomy (ES). In 164 patients common bile duct stones were proven and treated endoscopically, without performing a subsequent cholecystectomy. All 164 patients were free of symptoms after the endoscopic intervention. This group of patients was compared with 78 patients who underwent cholecystectomy after endoscopic treatment of common bile duct stones. Patients were followed for 1-13 years after ERC and sphincterotomy results and complications were registered. RESULTS: The ages of the 164 patients in the in situ group were significantly higher than in the cholecystectomy group and the ASA classification (American Society of Anesthesiologists) was significantly higher in the in situ patients. Mean follow-up was 70.9 months. Of the in situ patients 27 (16%) returned with biliary symptoms; 12 with common bile duct stones, three with cholangitis, and one with stenosis of Vater's papilla. Eight patients returned with cholecystitis and 3 with symptomatic cholecystolithiasis. Thirteen patients underwent cholecystectomy and 11 were managed (also) endoscopically. Minor complications were 2 wound infections and 1 bleeding after cholecystectomy. Two patients (1%) died of abdominal sepsis due to cholecystitis. Of the patients who underwent cholecystectomy, 6 (7.6%) returned during follow-up. Three patients had common bile duct stones, 2 had cholangitis and 1 patient presented with papillostenosis. Three patients needed surgical common bile duct exploration and the other 3 were treated endoscopically. After reintervention, cardiopulmonary complications were observed in 1 patient. There was no related death. CONCLUSION: When common bile duct stones are treated successfully by endoscopic sphincterotomy and patients are free of symptoms, there is no need for routine prophylactic cholecystectomy.     

Comparison of emergent versus elective laparoscopic common bile duct exploration for patients with or without nonsevere acute cholangitis complicated with common bile duct stones

Background

Laparoscopic common bile duct exploration (LCBDE) has already been established for the treatment of patients with common bile duct stones (CBDS) in elective situations. However, the effect of emergent LCBDE on those patients with nonsevere acute cholangitis has not been assessed. The aim of this study was to evaluate the effect of emergent LCBDE on patients with nonsevere acute cholangitis complicated with CBDS.

Methods

Seventy-two patients with CBDS admitted from January 2009 to December 2012 were included for this retrospective study. LCBDE of transductal approach for CBDS was performed to all patients. Thirty-seven patients underwent emergent LCBDE for nonsevere acute cholangitis and 35 patients underwent elective LCBDE. Duration of the procedure, complications, retained stone of bile duct, hospital stay, and total charges were compared between the two groups. In addition, the characteristics of patients underwent emergent LCBDE were also compared before and after surgery.

Results

There was no significant difference with regard to the diameter of common bile duct and number of CBDS from imaging and/or operative findings between the two groups. There was no conversion to open common bile duct exploration, no major bile duct injuries, and no mortality in both the group of patients. There was no significant difference in patients with or without acute or chronic cholecystitis, duration of surgery, overall hospital stay (16.41 ± 1.03 versus 14.54 ± 0.94, P > 0.05), and total charges (18,603 ± 1774.64 versus 14,951 ± 1257.09 Yuan in renminbi, P > 0.05) between the two groups. Four cases with retained stones were found in patients with emergent LCBDE and two in elective LCBDE patients. There were four cases of biliary leak in patients with emergent LCBDE and three cases in elective LCBDE group, respectively. However, there was no statistical difference between the two groups. The biliary leak was cured postoperatively after drainage. Control of septic symptoms was achieved in all patients after emergent LCBDE.

Conclusions

Our data indicated that emergent LCBDE is as safe and effective as elective LCBDE for the treatment of patients with nonsevere acute cholangitis complicated with CBDS.     

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。     

胆总管一期缝合治疗胆总管结石疗效及术后胆漏危险因素分析

目的比较胆总管结石患者行胆总管一期缝合及T管引流术的疗效,并探讨胆总管一期缝合术后胆漏的危险因素。方法回顾性分析2010年1月至2016年8月安徽省阜南县人民医院收治并完成胆总管探查术的183例患者临床资料,其中胆总管一期缝合(观察组)82例,T管引流(对照组)101例,分析比较两组的治疗效果,并对胆总管一期缝合术后胆漏发生的相关因素进行单因素分析和Logistic回归多因素分析。结果两组均顺利完成手术,围手术期无死亡病例。两组手术时间、术中出血量、腹腔引流管留置时间比较,差异均无统计学意义(P0.05);而在术后肛门首次排气时间、术后住院时间上,两组差异有统计学意义(P0.05)。实施胆总管一期缝合术的82例患者中,8例发生术后胆漏(9.76%),单因素分析结果显示:胆道手术史、术前血白蛋白水平、术前总胆红素与一期缝合术后胆漏有关(P0.05);多因素分析结果表明:术前胆红素水平以及术前血清白蛋白水平是影响胆总管一期吻合术后胆漏的独立危险因素(P0.05)。结论胆总管一期缝合术的临床疗效优于T管引流术;胆总管一期缝合术后胆漏受多种因素影响。为减少术后胆漏的发生,术者需具备熟练的手术缝合技术(包括腔镜缝合技术)。需开展大样本、多中心的前瞻性随机对照研究来进一步明确胆总管切开后一期吻合和T管留置的手术适应证。     

腹腔镜胆道探查胆总管一期缝合术治疗胆管结石的疗效分析

目的探讨腹腔镜下胆道探查术、胆总管一期缝合术的临床疗效与可行性。方法2014年2月至2017年2月收集贵州医科大学附属医院106例胆总管结石病人,男性44例、女性62例,年龄18~75岁,平均(46.5±15.7)岁。106例胆总管结石病人,伴或不伴胆囊结石与肝内胆管结石,其中腹腔镜下胆道探查胆总管一期缝合术67例,腹腔镜下胆道探查T管引流术39例,对两组病例手术适应证、手术时间、术后恢复情况、并发症等进行比较。结果胆总管一期缝合组的手术时间、术后住院天数、腹腔引流管放置时间分别为(72.8±21.0)min、(2.8±1.9)d和(5.5±2.3)d,优于T管引流术组的(95.5±26.5)min、(5.7±1.4)d和(8.1±2.6)d(均P0.05),术后肛门排气时间两组分别为(1.9±0.8)d和(2.1±0.5)d、差异无统计学意义;两组均无肝衰竭、腹腔感染、胆管残余结石、胆道出血及穿孔,胆漏发生率T管引流术组(3例)高于胆总管一期缝合组(0例)(P0.05)。结论腹腔镜胆道探查胆总管一期缝合术治疗胆管结石是安全、可行的,病人明显受益,值得临床推广应用。     

Spontaneous passage of bile duct stones: frequency of occurrence and relation to clinical presentation

BACKGROUND: Little is known about the spontaneous passage of bile duct stones. The aim of this study was to determine the rate of spontaneous stone passage and relate it to the clinical presentation of the bile duct stone. PATIENTS AND METHODS: Prospectively collected data were studied on a total of 1000 consecutive patients undergoing laparoscopic cholecystectomy with or without laparoscopic common duct exploration. Comparisons were made between 142 patients with common bile duct stones (CBDS), 468 patients who had no previous or current evidence of duct stones, and 390 patients who had good evidence of previous duct stones but none at the time of cholecystectomy. The evidence used for previous duct stones included a good history of jaundice or pancreatitis. In patients with biliary colic or cholecystitis, abnormal pre-operative liver function tests and/or a dilated common bile duct were taken as evidence of bile duct stones. RESULTS: Of the 1000 patients studied, 532 had evidence of stones in the common bile duct at some time prior to cholecystectomy. At the time of operation, only 142 patients had bile duct stones. By implication, 80%, 84%, 93% and 55% of patients presenting with pancreatitis, colic, cholecystitis and jaundice (73% overall) had passed their bile duct stones spontaneously. All 4 patients with cholangitis had duct stones at the time of operation. CONCLUSIONS: It is likely that most bile duct stones (3 in 4) pass spontaneously, especially after pancreatitis, biliary colic and cholecystitis but less commonly after jaundice. Cholangitis appears to be always associated with the presence of duct stones at the time of operation.     

Common bile duct obstruction associated with a dacron H-graft portacaval shunt.

An unusual patient had ascending cholangitis secondary to common bile duct obstruction by stones and a Dacron graft previously utilized in the performance of an H-graft portacaval shunt. Erosion of this foreign body into the common bile duct appeared to be secondary to bacterial contamination of the graft and direct contact of the foreign material with the biliary tree.     

腹腔镜下治疗胆囊结石合并胆总管结石的疗效影响因素分析

目的:探讨影响腹腔镜手术治疗胆囊结石合并胆总管结石疗效的相关因素。方法:回顾分析2009年6月至2011年6月为128例胆囊结石合并胆总管结石患者行腹腔镜手术的临床资料,根据患者术后是否复发将其分为复发组及未复发组,分别采用单因素及Logistic回归模型分析影响胆囊结石合并胆总管结石术后复发的相关因素。结果:24例术后复发,复发率18.75%。经单因素分析得出,年龄、胆总管直径、结石数量、胆总管扩张、胆囊管扩张、胆管炎、总胆红素异常、胰腺炎、结石残留、术后合并症、黄疸、结石直径及手术类型与胆囊结石合并胆总管结石术后复发相关。经Logistic回归模型分析可知,胆总管直径、胆囊管扩张、胆总管扩张、结石数量、胆管炎、结石残留、术后合并症及手术类型是影响胆囊结石合并胆总管结石患者术后复发的独立危险因素。结论:腹腔镜手术治疗胆囊结石合并胆总管结石术后复发的影响因素较多,临床应根据患者具体情况制定相应的预防控制措施,以降低术后复发率。     

Laparoscopic surgery and the common bile duct

Many biliary tract surgeons have now reached a level of sophistication with laparoscopic cholecystectomy that they are now able to deal with the common bile duct at the same time. Preoperative endoscopic cholangiography can be reserved for cases where choledocholithiasis has a high degree of probability. This has served to decrease the number of negative studies. The surgeon has five choices regarding stones confirmed by operative cholangiography during laparoscopic cholecystectomy: (1) do nothing, hoping the stones will pass spontaneously or that a postoperative sphincterotomy with stone extraction will be successful; (2) perform a transcystic laparoscopic common bile duct exploration (best for stones less than 1 cm and distal to the cystic duct); (3) perform a laparoscopic common bile duct exploration by choledochotomy (best for large stones in patients with common bile ducts greater than 1 cm. It is also the preferred approach with stones proximal to the insertion of the cystic duct.); (4) perform an intraoperative sphincterotomy with stone extraction, either retrograde or antegrade (this approach has some proponents but has not gained popularity among the majority of surgeons); and (5) place a double lumen catheter through the cystic duct with a proximal lumen in the common bile duct and the distal lumen in the duodenum. This can be used for serial postoperative cholangiography to confirm spontaneous stone passage or falsely positive operative cholangiograms. It is useful in situations when laparoscopic common bile duct exploration equipment or surgeon expertise is not available. If stones persist, a guidewire can be introduced through the distal lumen of the catheter for a guidewire-assisted sphincterotomy. Other CBD interventions that have been reported include laparoscopic biliary bypass and resection of choledochal cysts. Malignant lesions should not be approached by a laparoscopic method except in unusual circumstances.     

The management of retained and recurrent bile duct stones

The records of 156 consecutive patients treated for retained and recurrent bile duct stones between 1965 and 1980 were reviewed to compare current management techniques. One hundred sixty-eight procedures were performed in the 156 patients: 36 endoscopic sphincterotomies, 89 common bile duct explorations, and 43 common bile duct explorations with drainage procedure. Mean follow-up was 7.2 years. The overall success rates were 81% for endoscopic sphincterotomy, 80% for common bile duct exploration, and 86% for common bile duct exploration with drainage procedure. Five variables were evaluated in regard to the success of these procedures: (1) the time interval between cholecystectomy and the next procedure on the biliary system, (2) the number of previous biliary procedures or operations performed, (3) the diameter of the common bile duct, (4) the number of stones in the duct and their size, and (5) morbidity and mortality. The time interval and number of previous biliary procedures did not affect the success of any procedure group. Endoscopic sphincterotomy has become our procedure of choice. When common bile duct exploration with drainage procedure is performed and a dilated bile duct or more than five bile duct stones are found, the addition of a drainage procedure provides better long-term results.     

Laparoscopic transcystic bile duct stenting in the management of common bile duct stones

Background : The management of patients with common bile duct stones associated with stones in the gall bladder remains controversial. Methods : Over the three‐year period from 1996 to 1999, patients with cholelithiasis and known choledocholithiasis, or choledocholithiasis found at laparoscopic cholecystectomy, were initially treated by placing a stent across the sphincter of Oddi. The stent was pushed along a guide wire through the cystic duct and then down the common bile duct, before the cystic duct was closed. Subsequently, the stent was used to facilitate performance of a needle knife endoscopic sphincterotomy. The stent was then removed, a cholangiography was performed and the common bile duct was cleared. Patients with persistent jaundice usually had a preoperative endoscopic retrograde cholangio‐pancreatography. Results : Transcystic stenting was the ‘intention‐to‐treat’ basis of therapy for 56 of the patients. The placement of the stent only failed once when the stent became trapped in the cystic duct. Complications of the operation included: pain and jaundice (n = 2), cholangitis (n = 1), and pulmonary embolus (n = 1). The median postoperative hospitalization was 2 days (range: 1–15). Five further patients had common bile duct stones removed via a choledochotomy; a stent was placed through the choledochotomy before its closure. The selective common bile duct cannulation rate at the first endoscopic retrograde cholangio‐pancreatography, was 98%. A second endoscopic retrograde cholangio‐pancreatography was required in 15% of patients. The only complication of all the endoscopic procedures was a single case of mild cholangitis; there were no cases of pancreatitis. Conclusion : A treatment option open to all surgeons for non‐jaundiced patients with known choledocholithiasis or choledocholithiasis found at operative cholangiogram, is the transcystic stenting of the sphincter of Oddi at the time of laparoscopic cholecystectomy. At a subsequent sitting, the common bile duct can be safely cleared endoscopically using a sphincterotomy facilitated by the stent.