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PubMed1995

[Minimally invasive surgery--choledocholithiasis: therapeutic splitting].

Patients with cholecysto- and choledocholithiasis may benefit from the advantages of laparoscopic cholecystectomy by intraoperative common bile duct exploration or preoperative endoscopic papillotomy (EPT) with stone removal. We performed therapeutic splitting in 94 patients. Morbidity was 4.2% and mortality was zero. A follow up study of 50 patients shows residual stones in 2% and papillary stenosis in 2%. We believe our results, supported by data on EPT in the literature, show that two-stage endoscopic stone removal prior to laparoscopic cholecystectomy is a safe and effective method for treating cholecystolithiasis combined with choledocholithiasis.

Adult↗
PubMed1994

An institutional review of the management of choledocholithiasis in 1616 patients undergoing laparoscopic cholecystectomy.

At Georgia Baptist Medical Center, 1616 patients underwent laparoscopic cholecystectomy between December 1989 and December 1992; and 103 perioperative endoscopic retrograde cholangiopancreatography (ERCP) procedures were performed, 79 preoperative and 24 postoperative. Endoscopic sphincterotomy with stone extraction was performed in 49 patients (4.7%). Normal ERCP was noted in 46 patients (44%), four patients failed stone extraction preoperatively, and two patients failed extraction postoperatively (5.7%). Four patients had small stones (< 2 mm) managed expectantly without sphincterotomy. Ten laparoscopic common bile duct explorations and eight open common bile duct explorations were performed without retained stones after these procedures. The incidence of detected choledocholithiasis requiring intervention was 4.4 per cent, which is significantly lower than the published incidence of 8 to 15 per cent. It is assumed that a higher percentage of stones may have been detected with liberal or routine use of cholangiography. The clinical significance of these potentially missed stones have not been manifest in our series to date. The authors believe that although improved patient selection may lower the percentage of normal ERCP, this combination of minimally invasive techniques provides a satisfactory approach to choledocholithiasis.

Cholangiography↗
PubMed1993

Long term results of choledochoduodenostomy versus choledochojejunostomy for choledocholithiasis. The French Association for Surgical Research.

The current randomized study was done to compare the results of choledochoduodenostomy (CD) and choledochojejunostomy (CJ) for choledocholithiasis, with special reference to long term results and the risk of ascendant cholangitis. From January 1978 to January 1990, 130 patients were included in the study--64 with CD (side to side, in all patients) and 66 with CJ (side to side in 25 patients and end to side in 41). No significant difference was observed between the CD and CJ groups for postoperative mortality (3.8 percent) and morbidity rates. One hundred and twenty patients (58 CD and 62 CJ) were available for long term follow-up evaluation (mean follow-up period of 29 +/- 11 months). One hundred and seven patients had no symptoms attributable to biliary disease or operation. Five patients in this group died of unrelated causes. Thirteen patients experienced biliary symptoms suggestive of cholangitis, or at least related to the bilioenteric anastomosis--six patients in the CD group and seven in the CJ group. Cholangitis was observed in the first postoperative year in eight of these 13 patients and during the second year for the five others. In the CD group, cholangitis was the result of sump syndrome (n = 3), anastomotic stricture (n = 1) and unknown causes (n = 2). In the CJ group, cholangitis was the result of anastomotic stricture (n = 3), residual intrahepatic stones (n = 1) and unknown causes (n = 3). The results of the current study confirm the good long term results of both procedures. However, it suggests that CD is preferable for choledocholithiasis for two reasons--it is technically easier and faster to perform than CJ and, unlike CJ, CD permits easy access to further endoscopic exploration or treatment if necessary.

Aged↗
PubMed1993

[The ultrasonic diagnosis of choledocholithiasis].

The results of examination and treatment of 162 patients with clinically suspected choledocholithiasis were analysed. The high significance of ultrasonic examination in the diagnosis of a calculous nature of the affection of the biliary tree with a record of its echosemeiotics is shown. The wide use of ultrasonic examination yields better information. Study of the results of complex examination of 110 patients with verified choledocholithiasis confirmed the high rarefying capacity of the ultrasonic method in the detection of stones in the extrahepatic biliary tree (85.8% accuracy of the examination) both when it is applied for the first time and when it is used during the treatment. Obligatory performance of ultrasonic examination in diseases of the extrahepatic biliary ducts is suggested.

Adult↗
PubMed1993

[Significance of laparoscopic surgery in the treatment of cholecysto- and choledocholithiasis].

The management of common bile duct stones during laparoscopic cholecystectomy contains some controversy. Our first aim is to detect choledocholithiasis preoperatively making use of a preoperative ultrasound and cholangiogram routinely. Laparoscopic cholecystectomy will follow a preoperative ERCP with endoscopic sphincterotomy and stone extraction in this desirable situation. Cystic duct cholangiography which should become a routine procedure during laparoscopic surgery is feasible in 90-99% and will detect unsuspected common duct stones and iatrogenic bile duct injuries with an accuracy rate of 75.4-90%. This investigation can replace the preoperative cholangiogram in future. A intraoperatively detected common bile duct stone can be managed nowadays by ERCP and sphincterotomy postoperatively or by converting the laparoscopic cholecystectomy into an open common bile duct exploration. Laparoscopic common bile duct exploration is of increasing demand but not yet a routine procedure. If choledocholithiasis will be diagnosed postoperatively, a ERCP with papillotomy will be performed as well. An inquiry among 50 members of the Swiss society of laparoscopic and thoracoscopic surgery (ALTC) with 3718 laparoscopic cholecystectomies pointed out their opinion about the management of common bile duct exploration during laparoscopic surgery in the presented paper.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1993

Endoscopic retrograde cholangiopancreatography in the management of choledocholithiasis with laparoscopic cholecystectomy.

With the advent of laparoscopic cholecystectomy, endoscopic retrograde cholangiopancreatography (ERCP) has an increasing role in perioperative management. To assess this role, the authors studied, retrospectively, 12 patients who underwent ERCP out of a series of 475 who had laparoscopic cholecystectomy. ERCP was indicated preoperatively for biliary colic in four patients, gallstone pancreatitis in two and common bile duct stone on ultrasonography in one. ERCP was performed postoperatively for jaundice in three patients, for cholangitis in one and for a positive intraoperative laparoscopic cholangiogram in one. Choledocholithiasis was diagnosed in six patients preoperatively and in three postoperatively. Only one patient had an unsuspected residual bile duct stone postoperatively. Of nine patients with stones, endoscopic sphincterotomy was performed in eight and stones were cleared in all with no complications; a stone passed spontaneously in the other patient. ERCP is indicated before laparoscopic cholecystectomy in cases of jaundice, gallstone pancreatitis, cholangitis, abnormal liver biochemistry suggesting cholestasis and ultrasonographic demonstration of either a common bile duct stone or a common bile duct greater than 8 mm in diameter. Operative laparoscopic cholangiography is indicated when the anatomy is unclear or the bile duct appears dilated. If choledocholithiasis is founded, the options include open or laparoscopic common bile duct exploration and intra- or postoperative endoscopic sphincterotomy.

Adult↗
PubMed1996

Management of choledocholithiasis encountered during laparoscopic cholecystectomy.

To evaluate the prevailing methods of management and assess the safety of laparoscopic treatment of choledocholithiasis, a retrospective review of all common bile duct explorations (CBDE) initiated during laparoscopic cholecystectomy at the Medical College of Georgia was performed. From December 1990 until December 1994, 604 laparoscopic cholecystectomies were performed. In 28 of these patients (26 female, 2 male) with an age range of 17 to 60 years, CBDE was initiated; 21 were performed laparoscopically, and 7 were converted to open CBDE. The procedure was successful in completely clearing the duct of stones in 24 of 28 cases (17 laparoscopic, 7 open). Postoperative endoscopic retrograde cholangiopancreatography was successfully employed in three of the cases of retained stones, and in the fourth, the stone was felt to be small enough to pass without further intervention. Biliary balloon catheters were successfully used to clear the duct in 8 of 17 laparoscopic CBDEs, and a laparoscopic choledochoscope introduced through the cystic duct was used in 7 cases; both were used in 2 cases. The open CBDEs were performed in standard fashion utilizing balloon catheters and choledochoscopy. The only operative complications were the four above-mentioned cases of retained stones. In summary, choledocholithiasis encountered during the course of laparoscopic cholecystectomy can frequently be managed with a laparoscopic CBDE.

Adolescent↗
PubMed1996

Stenting for choledocholithiasis: temporizing or therapeutic?

Maxton and colleagues report their experience using biliary endoprostheses for treatment of failed common bile duct stone clearance after sphincterotomy. Of 283 patients with choledocholithiasis referred to their tertiary facility, 85 failed to have their ducts cleared with the first ERCP. There were 21 male and 64 female subjects; mean age was 77.5 yr. Clinical presentations were jaundice (39), cholangitis (23), and biliary colic and/or abnormal liver blood tests in the remainder. The patients were characterized as "elderly and ill with either jaundice or cholangitis present in almost 75%." Follow-up data were obtained for all patients. ERCP was first performed using a duodenoscope with a 3.2-mm instrument channel. A 7-French double pigtail stent was placed in each of the 85 patients with retained stones. Subsequent ERCP were performed at 2- to 3-month intervals using a therapeutic duodenoscope (4.2-mm instrument channel). A second stent was placed if stones remained in the bile duct after repeated extraction attempts. Patients deemed too frail and elderly for frequent ERCP had their first stent left in place, with stent exchanges and attempts at stone extraction every 6-12 months. Mechanical lithotripsy was used in 23 patients, extracorporeal shock wave lithotripsy (ESWL) in 11, and dissolution therapy via nasobiliary catheter in 10. Acute illnesses resolved in 84 of 85 patients, with significant decreases in bilirubin and alkaline phosphatase levels by the second ERCP. Six patients died with temporary stents in situ, one form a respiratory arrest the day of ERCP; the other deaths were unrelated to ERCP or choledocholithiasis. Fifty of the remaining 79 patients had successful stone clearance; 68% of these required two ERCP, 20% three ERCP, 6% four ERCP, and, in another 6%, a total of five ERCP were required before their ducts were free of stones. Seven cases of cholangitis among these 50 patients were treated successfully with i.v. antibiotics, fluids, and "early" stent replacement. Twenty-six patients had long term biliary drainage with the original stents in situ over 12 months. Four of these patients were among the six deaths, all unrelated to biliary stones or ERCP. Three patients were referred for surgical stone removal. The authors conclude that placement of a single 7-French stent after failure to clear common duct stones is safe, provides affective biliary drainage, can prevent the need for urgent surgical intervention, and allows for transfer of sick patients to centers of expertise. Further attempts at bile duct clearance were successful in most cases.

Aged↗
PubMed1996

Cost-effective management of complicated choledocholithiasis: laparoscopic transcystic duct exploration or endoscopic sphincterotomy.

BACKGROUND: In the United States of America, approximately 700,000 patients undergo laparoscopic cholecystectomy (LC) each year and at least 10 percent of these patients will have common bile duct stones (CBDS). The purpose of this study was to evaluate patients with choledocholithiasis and compare the economic and clinical results obtained by LC with endoscopic sphincterotomy (ES) with those of LC with laparoscopic transcystic common bile duct exploration (LTCBDE). STUDY DESIGN: From June 1991 to September 1994 patients undergoing LC plus LTCBDE and those undergoing LC plus ES at a single institution were compared where cost data were available. Of the 76 patients with choledocholithiasis, 59 patients underwent LC plus LTCBDE (group 1) and 17 patients underwent LC plus ES (group 2). A subset of group 1 patients undergoing urgent LC plus LTCBDE (group 3) for cholecystitis, cholangitis, or pancreatitis plus laparoscopy were examined separately. RESULTS: Laparoscopic cholecystectomy plus LTCBDE, whether including all-comers (group 1) or just urgent cases (group 3), was associated with a significantly decreased length of hospital stay (6.1 and 6.9 days, respectively, compared with group 2, 12.4 days) (p < 0.001). The morbidity of patients in group 1 was also markedly lower than for patients in group 2; 12 percent compared with 41 percent, respectively. Patients in group 1 had a significantly decreased cost of hospitalization (+13,151), when compared with patients in group 2 (+18,712) (p = 0.05). This difference is even more pronounced when professional fee reimbursement is considered. The cost of treatment for patients in group 1 was +14,732 compared with +21,125 for patients in group 2 (p < 0.05). The total hospital cost for patients in group 3 was only +13,564 compared with +18,712 for patients in group 2. When professional reimbursement was considered, the cost was +15,150 for patients in group 3 compared with +21,125 for patients in group 2. CONCLUSIONS: Patients undergoing LC plus LTCBDE for CBDS, whether urgently or electively, have markedly decreased morbidity rates, length of hospital stay, and costs when compared with patients undergoing LC plus ES.

California↗
PubMedDate not supplied

Transduodenal sphincteroplasty in the treatment of choledocholithiasis in pregnancy.

Transduodenal sphincteroplasty is a safe, effective, reliable procedure in the treatment of choledocholithiasis. The fact that it can be practiced without radiographic surveillance makes it uniquely applicable during pregnancy. There are no reports applying this mode of treatment to the pregnant woman with choledocholithiasis.

Adult↗
PubMed1997

[Treatment with endoscopic endoprosthesis in choledocholithiasis].

The results of the placement of endoscopic endoprosthesis in 51 patients with choledocholithiasis from October 1991 to December 1995 are reviewed. In 13 cases the endoprosthesis was provisionally placed. Surgical or endoscopic treatment was electively completed in all the cases. Thirty-eight patients received the endoprosthesis on a permanent basis. During the follow up (mean 15.2 months) extraction was completed and the prosthesis removed in three cases, one by emigration. Six patients presented recurrent biliary obstruction and underwent surgery or replacement of another prosthesis. In the latter cases, another two underwent surgery due to repeated obstructions. The remaining patients remained asymptomatic until the end of follow up or until death (8 cases) due to unrelated causes. Only three mild episodes of cholangitis were observed as complications related to prosthesis placement. The authors conclude that endoscopic endoprosthesis is an effective provisional treatment to solve acute situations and is a permanent alternative for unextracted choledocholithiasis following sphincterotomy in patients who cannot undergo other techniques and who have a short life expectancy.

Aged↗
PubMed1997

[Extracorporeal lithotripsy in combination with endoscopic papillotomy in choledocholithiasis].

Results of treatment of 30 patients of 50 to 90 years of age having choledocholithiasis by the method of extracorporeal lithotripsy (EL) combined with endoscopic operations on the major duodenal papilla are described. The first stage in the treatment was endoscopic papillosphincterotomy. There were 41 sessions of EL (at an average 1,37 procedure for each patient). In 15 patients spontaneous excretion of the fragments from the common bile duct was noted. The endoscopic sanitation of the common bile duct with a removal of fragments with the Dormia basket was fulfilled in 13 patients after EL. The method of choledocholithotomy proved to be ineffective in 2 patients. Sanitation of the common bile duct was performed in all the patients before their discharge from the hospital. Thus the results obtained allow considering the extracorporeal biliary lithotripsy when combined with endoscopic papillosphincterotomy as an effective method for treatment of patients with choledocholithiasis which not only supplements traditional surgical procedures but also may be used as an alternative method of treatment especially for patients with high operative risk.

Aged↗
PubMed1998

[Initial experience with treatment of choledocholithiasis using shock waves].

From March 1996 till August 1997 at the First Surgical Clinic in Olomouc 18 patients with concrements in the biliary pathways were treated by shock waves. All patients were older than 68 years; residual choledocholithiasis was involved which could not be eliminated during ERCP because of the size of the size of the stone. In 125 instances treatment was successfully terminated, i.e. by crushing the stones and their elimination. Only in three patients it was necessary to resolve the situation by surgery. The authors confirmed that it is possible to treat by this method patients with choledocholithiasis and avoid the risk of surgery in particular in older patients.

Aged↗
PubMed1998

[Recurrent and residual choledocholithiasis].

Many years' experience in treatment of 617 patients with choledocholithiasis (ChDL) served the basis for analysis of the causes of residual (72.4%) and recurrent (21.4%) lithiasis of bile ducts in patients with postcholecystectomy syndrome. In 6.2% of cases identification of the type of ChDL was not a success. Recommendations in prophylaxis of recurrent as well as residual lithiasis are given. In 78.5% of patients with residual stones after primary operation choledochotomy with removal of the stones was made with cholecystectomy but as was evidenced later not all the stones were removed. Data on diagnostic value of clinical symptoms and US examinations for revealing ChDL are presented. ChDL without jaundice was detected in 47.4% of patients. Current diagnostic facilities in primary choledocholithiasis before the operation and intraoperative are discussed. After choledochotomy, if there are no contraindications, it is recommended to finish the operation by external drainage of bile ducts with the use of T-shaped drainage tube. If residual ChDL is detected, it would be reliably eliminated without surgery.

Choledochostomy↗
PubMed1998

Endoscopic management of choledocholithiasis: to cut, stretch or relax?

Since it was first described in 1974, endoscopic sphincterotomy has been the procedure of choice for management of choledocholithiasis, especially for retained common bile duct stones. However, it has the dubious distinction of being the most hazardous of all endoscopic retrograde cholangiopancreatographic procedures and carries an immediate complication rate of 8-10%. Concern has also been voiced about the long-term complications of sphincterotomy, as the sphincter of Oddi is cut during the procedure. To prevent, or at least lessen, the short- and long-term complications of endoscopic sphincterotomy, an alternative in the form of balloon dilatation of the papilla, has been advocated. However, the procedure of balloon dilatation is cumbersome, time consuming and, more importantly, a recent multi-centre study from the US comparing endoscopic sphincterotomy with balloon dilatation observed higher complications with balloon dilatation. The use of nitrites to relax the papilla is another novel method used for removal of common bile duct calculi. So how should a therapeutic endoscopist decide which method is to be used? The advantage of endoscopic sphincterotomy is that it has been around for more than two decades and most endoscopists are familiar with the technique as well as its complications. It can be accomplished quickly and with the advent of wire-guided and balloon-mounted sphincterotomes, the time taken for the procedure to be completed has been reduced further. The complications of the procedure are less when it is employed for removal of common bile duct stones and when used by experts. It, therefore, still appears to be the procedure of choice for endoscopic management of choledocholithiasis. The other two methods may, however, be useful in patients with coagulopathy.

Animals↗
PubMed2007

Optimizing choledocholithiasis management: a cost-effectiveness analysis.

HYPOTHESIS: Endoscopic retrograde cholangiopancreatography (ERCP) is more cost-effective for managing incidental choledocholithiasis (CDL) after laparoscopic cholecystectomy and intraoperative cholangiogram (LC/IOC) than laparoscopic common bile duct exploration (LCBDE). DESIGN: A cost-effectiveness analysis was performed to compare ERCP with LCBDE. Sensitivity analyses were performed to determine the key contributors to cost-effectiveness between the 2 treatment options. SETTING: Costs were approached from the institutional perspective considering a typical patient undergoing LC/IOC at a large referral center. PATIENTS: The base case patient evaluated was a woman 18 years of age or older with symptomatic cholelithiasis and incidental CDL discovered at the time of LC/IOC. INTERVENTIONS: Endoscopic retrograde cholangiopancreatography with drainage procedure performed after LC/IOC or LCBDE during LC/IOC. MAIN OUTCOME MEASURES: Costs, quality-adjusted life years gained, mean cost-effectiveness ratios, and incremental cost-effectiveness ratios. RESULTS: In the base case analysis, ERCP was the optimal treatment choice with a cost of $24 300 for 0.9 quality-adjusted life years gained compared with $28 400 and 0.88 quality-adjusted life years for LCBDE. Endoscopic retrograde cholangiopancreatography remained the optimal strategy for CDL in multiway probabilistic sensitivity analysis. If LCBDE were performed and the cost of a potential operative case lost was $3100 or less and the cost of ERCP hospitalization was $18 000 or more, then LCBDE became the preferred treatment for CDL. CONCLUSIONS: Endoscopic retrograde cholangiopancreatography was both less costly and more effective than LCBDE. Factors important to choosing the best strategy for CDL management included the cost of a potential case lost due to LCBDE performance and the cost of ERCP hospitalization.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed2004

Accuracy of computed tomographic intravenous cholangiography (CT-IVC) with iotroxate in the detection of choledocholithiasis.

To determine the accuracy of computed tomographic intravenous cholangiography (CT-IVC) for detection of choledocholithiasis. Sixty-five patients undergoing endoscopic retrograde cholangiography (ERC) underwent CT-IVC prior to ERC, using a single detector helical CT following intravenous infusion of 100 ml iotroxate. Patients with bilirubin levels >3 times normal were excluded. ERC was indeterminate in three patients (4.7%) and CT-IVC in four (6.3%). Twenty-three patients had ductal calculi at ERC, and CT-IVC was positive in 22, with two false positives and one false negative: sensitivity 95.6%, specificity 94.3%. Stones were multiple in nine and solitary in 14. Of the 14 solitary stones, ten were <or=5 mm and eight were <or=4 mm. The bilirubin level in positive cases was within normal in 20. Maximum intensity projection (MIP) reformats showed stones in only 27% of cases and surface rendered (SR) reformats in none. CT-IVC is highly accurate for detection of ductal calculi, including single small calculi, with a normal or near normal serum bilirubin. Axial images should be used for interpretation rather than MIP or SR reformats.

Bilirubin↗
PubMed2003

Choledocholithiasis caused by migration of a surgical clip into the biliary tract following laparoscopic cholecystectomy.

As experience with laparoscopic cholecystectomy (LC) has increased, so have the number and variety of complications. We report a case of choledocholithiasis caused by migration of a surgical clip applied during LC. A 57-year-old Japanese man who had undergone LC 6 years previously was referred to our hospital with pruritus and jaundice. Magnetic resonance cholangiopancreatography and ultrasonography revealed a solid mass in the common hepatic duct and dilatation of the intrahepatic bile ducts. Abdominal arteriography demonstrated interruption of the right hepatic artery by surgical clips. Five days after a biopsy of the mass was performed through a percutaneous transhepatic biliary drainage tube, the mass moved to the terminus of the common bile duct along with one of the surgical clips. A basket catheter was used to remove the mass via endoscopy. Despite the fact that other clips in the common hepatic duct were partially exposed, the patient has been well for 2 years with no additional interventions.

Bile Ducts, Intrahepatic↗