Common bile duct stone characteristics: correlation with treatment choice during laparoscopic cholecystectomy |
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Authors: | Robert A Duensing M D Russell A Williams MD John Craig Collins MD Samuel E Wilson MD |
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Institution: | (1) Department of Surgery, University of California, Irvine Medical Center, Orange, Calif.;(2) Surgical Service, Long Beach Veterans Affairs Medical Center, Long Beach, Calif;(3) UC1 Medical Center, 101 The City Drive South, 92868 Orange, CA |
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Abstract: | Determining the most appropriate management approach for patients with unsuspected choledocholithiasis may be difficult because
of the subjective nature of this decision in the absence of clinical data. Treatment of incidental choledocholithiasis during
laparoscopic cholecystectomy was reviewed during a 25-month period. Operative cholangiograms were analyzed retrospectively
to determine if associations exist between common bile duct stone characteristics and the intraoperative treatment selected
by the operating surgeon. Cholangiographic data included quantification of common bile duct stones, stone dimension, position,
and presence of radiopaque contrast flow into the duodenum. Two hundred thirty-six laparoscopic cholecystectomy patients underwent
operative cholangiography; 25 (11%) demonstrated choledocholithiasis. Seven patients were converted to open common bile duct
exploration (group I), 16 patients were referred for postoperative endoscopic retrograde cholangiopancreatography (group II),
and two patients were observed (group III). Evaluation of the operative cholangiograms revealed multiple common bile duct
stones (> 1) in 86% (6 of 7) in group I, 25% (4 of 16) in group II, and none in group III. All patients in group I had at
least one stone larger than 5 ml in greatest diameter, whereas only 33 % (6 of 18) in groups II and III combined had stones
larger than 5 ml. Group I had significantly (P = 0.027) more representation of delayed or no contrast flow during operative cholangiography compared to groups II and III.
The intraoperative decision to proceed with laparoscopic cholecystectomy and rely on postoperative endoscopic retrograde cholangiopancreatography
for stone retrieval rather than open common bile duct exploration was associated with (1) a single common bile duct stone,
less than or equal to 5 ml in size on operative cholangiogram and (2) normal contrast flow into the duodenum. Open common
bile duct exploration was more frequently associated with the demonstration of multiple or large (>5 ml) stones. A periampullary
stone did not discriminate among treatment choices.
Presented at the Annual Scientific Meeting of the Southern California Chapter of the American College of Surgeons, Santa Barbara,
Calif., January 19–21, 1996. |
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Keywords: | Bile duct stones management characteristics decisions |
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