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PubMed1988

Prediction of choledocholithiasis using a pocket microcomputer.

A computerized method, using a small pocket computer, has been used to predict the presence of choledocholithiasis in a prospective series of 239 patients undergoing cholecystectomy. From an initial data base of 424 patients 36 factors were evaluated and the most important 2 of these were determined by multivariate analysis for use in the prospective analysis. Satisfactory operative cholangiograms were a prerequisite to evaluation of the statistical method and were obtained in 90.4 per cent of cases. Using the computerized method a common bile duct stone would have been overlooked in only 1 patient but 17 unnecessary explorations would have been carried out. The overall accuracy of the computerized method was 92.5 per cent. When the method was applied to a further study of 97 patients from a separate centre the overall accuracy was 85.6 per cent. If the method was used to aid selective use of operative cholangiography, cholangiograms would be performed in 20 per cent and stones would be overlooked in less than 1 per cent.

Cholangiography↗
PubMed1991

Long-term results of choledochoduodenostomy in the treatment of choledocholithiasis: assessment of 225 cases.

During a 10-year period 2610 patients were operated on for biliary lithiasis; in 225 (8.6 per cent) cases the operation concluded with a choledochoduodenostomy. The commonest preoperative diagnosis (62.2 per cent) in these 225 patients was choledocholithiasis; 30 patients had previously had a cholecystectomy. After choledochoduodenostomy, 4.0 per cent of patients had an intra-abdominal complication; six patients developed an intra-abdominal abscess and three developed an external biliary fistula. Four patients (1.8 per cent) died, three from pulmonary complications and one from a biliary fistula. After a mean follow-up period of 4.6 years, 71.5 per cent of patients were asymptomatic. The remainder suffered from dyspepsia (15.1 per cent), colicky pain (8.7 per cent) or episodes of cholangitis (4.7 per cent). Endoscopy in the symptomatic patients allowed the following conclusions: (a) no patient with dyspepsia had a problem at the anastomosis; (b) 27 per cent of those with colic had anastomotic stenosis or the sump syndrome; and (c) all patients with cholangitis had anastomotic stenosis and residual calculi.

Aged↗
PubMedDate not supplied

Improved sonographic visualization of choledocholithiasis.

Ultrasonographic diagnosis of gallstones in the distal part of extrahepatic duct is not easy. A number of new techniques have been used by the authors to improve the detection rate of these stones. They include filling the duodenum and gastric antrum with drinking water, scanning after a fatty meal, and changing the patient's position during scanning. Ultrasound successfully identified choledocholithiasis in 78 of 104 patients for a sensitivity of 75%. There were 26 false-negative cases. The chief causes of the false negatives were obscuration of the distal duct by overlying bowel gas, missing of small stone in a nondilated bile duct, and misdiagnosis of soft pigment or an impacted stone having an atypical hypoechoic image in the distal duct as a tumor. False-positive diagnosis occurred in 32 out of 188 noncalculous cases, giving a specificity of 83%. These cases represent various hyperechoic lesions in the neck of gallbladder, cystic duct, and periampullary region. The overall diagnostic accuracy of gallstones in the extrahepatic bile duct by ultrasound was 80% (234/292).

Gallstones↗
PubMed1994

Laparoscopic management of choledocholithiasis.

The authors report on a group of 114 patients with common bile duct (CBD) stones who were treated by laparoscopic surgery. Management through the cystic duct was considered the first option. Choledochotomy was used for those patients in which the cystic approach was not possible or was unsuccessful. Transcystic lithotripsy was considered for patients with CBD stones in disproportion with the size of the cystic duct. Laparoscopic antegrade sphincterotomy was indicated as a drainage procedure. The transcystic approach was used in 89.5% of the patients; choledochotomy was used in 6.2%; and both ways were used in 4.3%. Different procedures were used, including mechanical and electrohydraulic lithotripsy, choledochotomy with T-tube or endoprostheses drainage, laparoscopic sphincterotomy, end-to-end common bile duct anastomosis, and choledochoduodenum anastomosis. One of the patients was in the 21st week of pregnancy. The laparoscopic approach to choledocholithiasis was successfully performed in 94.8% of the patients. Mean hospital stay was 1.7 days. There was a 6.2% incidence of complications and the mortality rate was 0.9%. In 84.3% of the patients, the transcystic approach was used successfully, with a complication rate of 4.9% and a mean hospital stay of 1.6 days. Three patients were converted to open surgery early in this series. Thus far, one patients has presented residual CBD stones. The results obtained suggest that laparoscopic common bile duct exploration is a technically feasible procedure, with low complication and mortality rates, although it requires adequate selection of patients and a variety of techniques and types of equipment.

Common Bile Duct↗
PubMed1994

Preliminary experience with intracorporeal laparoscopic ultrasonography using a sector scanning probe. A prospective comparison with intraoperative cholangiography in the detection of choledocholithiasis.

Laparoscopic ultrasonography is a novel technique which may be useful in screening for choledocholithiasis during laparoscopic cholecystectomy. Following concerns regarding the "learning curve" and accuracy associated with the adoption of this user-dependent technology, we have prospectively evaluated a commercially available 90 degrees sector scanning laparoscopic ultrasound probe during elective laparoscopic cholecystectomy. Laparoscopic ultrasonography was performed in 60 patients and identified common duct stones in nine patients (one "false positive" and "one false negative"), and previously unsuspected duct stones were defined in three out of four patients. The gallbladder and portal vein were constantly defined anatomical landmarks throughout the study, whereas the suprapancreatic bile duct, intrapancreatic bile duct, and pancreatic duct were identified in 100%, 80%, and 85% of patients in the third consecutive group of 20 patients examined. Laparoscopic ultrasonography has the potential to accurately identify common duct stones during laparoscopic cholecystectomy and thereby implement a policy of "superselective" operative cholangiography. However, adequate training for surgeons unfamiliar with this technology is recommended.

Cholangiography↗
PubMed1987

Diagnosis and treatment of choledochocele complicated by choledocholithiasis (case report).

We report a case of choledochocele associated with choledocholithiasis. The patient became symptomatic when a gallstone was trapped within the choledochocele, causing intermittent biliary obstruction. Endoscopic retrograde cholangiography (ERC) provided the diagnosis and endoscopic sphincterotomy was performed for definite nonoperative treatment. The lesion could not be identified on ultrasound even after its demonstration by ERC. The importance of direct cholangiography in the diagnosis of a choledochocele is discussed.

Aged↗
PubMed1999

Biliary tract duplication accompanied by choledocholithiasis: report of a case.

Duplication of the biliary tract is extremely rare. In fact, to the best of our knowledge, only four previous reports of pediatric patients with this disease have been documented in the Japanese literature. This anomaly was diagnosed by perioperative endoscopic retrograde cholangiopancreatography (ERCP) in three of these patients, and incidentally during surgery for congenital biliary dilatation in the other one. We report herein a case of biliary tract duplication which was diagnosed by T-tube cholangiography, only in the oblique view, after cholecystectomy and choledochotomy with T-tube drainage. The patient was a 13-year-old girl who was initially diagnosed as having choledocholithiasis based on the results of preoperative and intraoperative cholangiography; however, a postoperative T-tube cholangiography revealed residual stones. At this point, duplication of the biliary tract was diagnosed only in the first oblique view. Reoperation was carried out 26 days after the first operation. The biliary tract was dissected completely from the pancreaticobiliary junction to the left and right hepatic ducts in the porta hepatis and found to be duplicated from the level of porta hepatis to the suprapancreatic area. We report our experience of this case, followed by a discussion on the relevant literature.

Adolescent↗
PubMedDate not supplied

Combination therapy of laparoscopic cholecystectomy and endoscopic transpapillary lithotripsy for both cholecystolithiasis and choledocholithiasis.

This report describes five patients with cholecystolithiasis and choledocholithiasis who were treated by combination endoscopic extraction of common bile-duct stones with sphincterotomy (EST) and laparoscopic cholecystectomy (LC). Following this combination procedure the patients were relieved completely of obstructive jaundice and right upper quadrant pain, leaving only small trocar insertion scars made during the short course of hospitalization. The combination therapy of EST and LC will be recommended for this kind of patient as a minimally invasive procedure.

Adolescent↗
PubMed2000

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.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1997

Choledocholithiasis after Billroth II surgery: MR cholangiographic diagnosis.

In this case of choledocholithiasis in a patient with previous Billroth-II surgery and cholecystectomy we demonstrate the advantages of a heavily T2-weighted half-Fourier turbo-spin-echo (HASTE) sequence. This technique allows thin-slice snapshot imaging with 1.4 s per slice eliminating motion artifacts and still has the necessary heavy T2-weighting to depict biliary fluid with high contrast. In the presented case endoscopic retrograde cholangiography (ERCP) could not be performed prior to MRI due to technical problems. In a second attempt, ERCP was successful and a common bile duct stone as diagnosed by MRI before could be removed. We conclude that HASTE snapshot MR cholangiography can be used as a clinically valuable tool when other noninvasive methods are not diagnostic.

Aged↗
PubMed2002

Treatment of choledocholithiasis in pregnancy: a case report.

Some difficulties have been encountered in treating pregnant patients with choledocholithiasis because of the probable harmful effect of scopic irradiation on fetus when endoscopic retrograde cholangiopancreatography (ERCP) is necessary. In this paper, we present such a patient, in whom endoscopic stone extraction without scopic examination was successfully carried out in the guidance of magnetic resonance cholangiopancreatography (MRCP) before the ERCP procedure.

Adult↗
PubMed2001

Selective operative cholangiography and Perioperative endoscopic retrograde cholangiopancreatography (ERCP) during laparoscopic cholecystectomy: a viable option for choledocholithiasis.

BACKGROUND: Most common bile duct (CBD) stones can now be removed by minimally invasive methods using pre- or postoperative endoscopic sphincterotomy. A few centers explore the bile duct laparoscopically, but not every hospital has access to the equipment for magnetic resonance (MR) cholangiopancreatography to diagnose ductal stones. This study shows the results of an alternative management option. METHODS: We did a retrospective review of perioperative endoscopic retrograde cholangiopancreatographies (ERCPs) and sphincterotomies that were performed on patients in whom choledocholithiasis had been revealed on operative cholangiogram. RESULTS: Thirteen patients underwent perioperative ERCP. Nine had successful duct clearance, three had failure to cannulate, and one was converted to an open procedure due to an anatomical problem. The combined median operating time for both procedures was 75 min and hospital stay was 2.5 days. No pancreatitis was reported. CONCLUSION: Selective operative cholangiography and perioperative ERCP during laparoscopic cholecystectomy is a viable option for the simultaneous management of CBD and gallbladder stones. Moreover, it helps to avoid unnecessary normal ERCP.

Adult↗
PubMed2003

Role of endoscopic retrograde cholangiopancreatography in the management of suspected choledocholithiasis.

BACKGROUND: Indications for endoscopic retrograde cholangiopancreatography (ERCP) are not precisely defined. With the increasing availability of magnetic resonance cholangiopancreatography (MRCP) and several prospective studies proving the accuracy of this modality, it is important to select appropriate criteria for invasive testing when common bile duct (CBD) pathology is suspected. METHODS: We reviewed 200 consecutive ERCPs performed for jaundice, pancreatitis, noninvasive visualization of CBD stones, radiologic evidence of CBD dilatation, elevated liver function tests, or biliary colic. Diagnostic and therapeutic yields are determined for each indication and various combinations thereof. RESULTS: Of the 180 ERCPs performed for suspected choledocholithiasis, 97 (53.8%) were performed for multiple indications, whereas 83 (46.2%) were performed for only one indication. One hundred two patients (56.6%) had CBD pathology, whereas 78 explorations (43.4%) were negative. If multiple indications for ERCP were present, the diagnostic yield was 85.6%. When there was only one indication, the diagnostic yield decreased to 25.3%. CONCLUSIONS: ERCP is an invasive procedure with significant morbidity that should be used selectively. MRCP may be a more appropriate initial evaluation of suspected CBD pathology in many patients.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1998

Laparoscopic common bile duct exploration by choledochotomy. An effective and efficient method of treatment of choledocholithiasis.

BACKGROUND: Management of cholelithiasis and choledocholithiasis usually requires two separate teams-the gastroenterologist/surgical endoscopist and the laparoscopic surgical team. This requires two separate procedures that potentially increase the overall morbidity and cost. Laparoscopic common bile duct exploration by choledochotomy (LCBDE-C) averts this problem with a single approach. METHODS: In 1990-1991, unsuspected stones found at laparoscopy with intraoperative cholangiogram done routinely underwent postoperative ERCP. Residual stones had been found after ERCP in 16 of 22 preoperative ERCP patients and we began to seek an alternative technique. Laparoscopic common bile duct exploration by choledochotomy has achieved a high rate of success. RESULTS: Technically successful LCBDE-C has been accomplished in 143 of 148 patients (96.6%). Retained bile duct stones have been found on postoperative cholangiogram in three patients (2.0%), all of which have been successfully removed by postoperative ERCP. Thus 140 or 148 patients had their bile duct successfully cleaned by the one-step technique alone (94.6%). CONCLUSIONS: We believe that most laparoscopic surgeons who have acquired the skills of intracorporeal suturing can be successful at laparoscopic common bile duct exploration by choledochotomy. The disadvantage of T-tube presence will likely be eliminated by future developments with intraoperative antegrade sphincterotomy-like procedures, but the ability to see both proximal and distal biliary tree with the choledochotomy in all cases seems to offer more than adequate results at this point in the evolution of the laparoscopic approach to calculus biliary tract disease.

Adult↗
PubMed1998

A comparison of laparoscopic ultrasound with digital fluorocholangiography for detecting choledocholithiasis during laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic ultrasound is an alternative to operative cholangiogram for evaluation of the common bile duct (CBD) during laparoscopic cholecystectomy. It is a safe, fast, and reliable method for detecting choledocholithiasis. METHODS: We prospectively evaluated the sensitivity and specificity of laparoscopic ultrasound (LUS) and digital fluorocholangiogram (DFCG) in a three-phase study of 360 consecutive patients. RESULTS: In phase I, 140 patients undergoing laparoscopic cholecystectomy had LUS performed first, followed by DFCG. Thirteen patients had CBD calculi identified on LUS. Four patients with confirmed (two cases) or presumed (two cases) CBD calculi on DFCG were not identified on LUS. Thus, the specificity of LUS was 100%, whereas the sensitivity was 76.5%. DFCG had four false positives, for a sensitivity of 100% with a specificity of 96.7%. LUS was performed, on average, in 6.6 min, whereas DFCG required 10.9 min to perform. In phase II, the infusion of saline through a cystic duct catheter was performed in instances where the distal CBD could not be well seen. This maneuver distended the intrapancreatic portion of the CBD, allowing better visualization. Nine stones were identified on LUS in 78 patients, increasing the sensitivity to 100%. One false positive DCFG was encountered, resulting in a sensitivity of 100% and a specificity of 98.6%. In phase III, we performed routine LUS and used DFCG only in select cases. The sensitivity and specificity for LUS were 95.7% and 100%, respectively, whereas DFCG had a sensitivity of 95.2% and a specificity of 100%. One patient in phase III has returned 11 months post-op with a CBD stone. This was initially missed on LUS, DFCG, and postoperative ERCP. The sensitivity and specificity in all 360 patients were 90% and 100% for LUS and 98.1% and 98.1% for DFCG, respectively. A total of five CBD stones were missed by LUS, four early in the study (phase I). One missed on LUS in phase III was also missed by DFCG and ERCP. CONCLUSIONS: LUS is a reliable alternative to DFCG during laparoscopic cholecystectomy (LC). With experience, it is as sensitive as DFCG and more specific. It is more rapidly performed than cholangiography.

Adult↗
PubMed2001

Choledocholithiasis in the Setting of Portal Hypertension.

The successful management of biliary lithiasis in patients with cirrhosis depends on the degree of liver dysfunction. Patients with Child-Pugh class A or B hepatic reserve have excellent prognoses. Endoscopic spincterotomy is first-choice treatment for cirrhotic patients with choledocholithiasis. Endoscopic sphincterotomy can be performed in patients with Child-Pugh class A, B, or C hepatic function. Medical treatment with contact solvents is contraindicated in patients with pigment stones or calcified stones.

Journal Article↗
PubMed1980

Recurrent choledocholithiasis following cholecystectomy, sphincterotomy and choledochoduodenostomy: successful treatment with chenodeoxycholic acid.

An elderly woman presented with recurrent choledocholithiasis. She had had three prior surgical procedures on the biliary tract, including a cholecystectomy with common duct exploration, a second common duct exploration with choledocholithotomy and sphincteroplasty, and subsequently a third common duct exploration with choledochoenterostomy. She refused further surgical therapy and chenodeoxycholic acid therapy was instituted. Within six months, there was partial dissolution of the gallstones. One year later, the stones were not longer demonstrable, and the patient was symptom-free. The potential role of chenodeoxycholic acid therapy, endoscopic papillotomy and postoperative extraction of common duct stones via the T-tube tract, using a Dormia basket, as alternates to surgical therapy of recurrent or retained gallstones are discussed.

Aged↗
PubMed1995

Managing choledocholithiasis in the laparoscopic era.

BACKGROUND: Management options for common bile duct stones have explained in the era of laparoscopic cholecystectomy (LC), and selecting the most appropriate method for each patient can be problematic due to the difficulty of predicting accurately which patients have choledocholithiasis (CDL). In order to improve selection of appropriate treatment for CDL, treatment options were analyzed for outcome retrospectively during a 25-month period beginning June 1, 1992. PATIENTS AND METHODS: Four hundred four patients underwent LC; 48 (12%) had CDL identified at preoperative endoscopic retrograde cholangiopancreatography (ERCP) or intraoperative cholangiogram (IOCG). Forty-seven patients were referred for preoperative ERCP for suspected CDL, 23 (49%) of whom had proven duct stones and underwent endoscopic sphincterotomy and stone retrieval with an 87% success rate. RESULTS: Of 357 patients scheduled for LC without preoperative ERCP, 236 had IOCG, of which 25 (11%) demonstrated CDL. Seven patients had open common bile duct exploration (CBDE). Sixteen patients had postoperative ERCP after positive IOCG, 7 (44%) of which were positive for CDL and whose stones were removed with 100% success. Two patients were observed, anticipating spontaneous passage of a small stone. CONCLUSIONS: Preoperative ERCP should be applied selectively. For the large majority of patients without preoperative evidence of CDL, we recommend routine IOCG; if CDL is demonstrated, an intraoperative decision can be made to proceed to postoperative ERCP in the usual case or to open CBDE for very large or multiple stones. Observation in anticipation of spontaneous passage may be appropriate for small, solitary common duct stones. Continuing advances in laparoscopic CBDE are likely to reduce further the need to rely on ERCP in managing CDL.

Cholangiography↗