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PubMed1999

Common duct diameter as an independent predictor of choledocholithiasis: is it useful?

We have evaluated the value of ultrasonographic measurement of common duct diameter in isolation from other predictors of choledocholithiasis. A cohort of 223 patients who did not have a history of jaundice or pancreatitis and had normal liver function tests underwent pre-operative ultrasound of the common hepatic duct and then had elective (open) cholecystectomy with operative cholangiography. One hundred and ninety-one (86%) of all patients had a normal (< or = 5 mm) common duct and of these only 12 (6%) had common duct calculi. Of the 32 patients who had a common duct diameter greater than 5 mm on pre-operative ultrasonography, 12 (37.5%) patients had ductal calculi. A pre-operatively dilated duct on ultrasonography has a high chance of containing stones and should be considered as a strong indication for pre-operative bile duct imaging or operative cholangiography.

Adult↗
PubMed2000

Choledocholithiasis: a prospective study of spontaneous common bile duct stone migration.

BACKGROUND: The rate of spontaneous migration of bile duct stones through the duodenal papilla is not well known. Endoscopic retrograde cholangiography (ERC) has been the standard method to diagnose bile duct stones, but accumulating data show there is a good agreement between ERC and endoscopic ultrasonography (EUS). The aim of the study was to evaluate the incidence and time course of stone migration in patients with bile duct stones by analyzing discrepancies between EUS and ERC as a function of the elapsed time between these two procedures. Stone migration was considered as the absence of stones at time of ERC regardless of the number of stones seen at EUS. METHODS: The main criterion for inclusion was the presence of bile duct stone as shown by EUS. Ninety-two consecutive patients were prospectively included in this study. RESULTS: Choledocholithiasis was absent at ERC in 12 patients. In univariate analysis, presence of gallbladder was significantly associated with an increased rate of stone migration (correction for multiple testing would remove this statistical significance). The size of the stone was the only independent factor to predict migration. CONCLUSION: Migration occurred in about 21% of cases within 1 month. Our study emphasizes the need to analyze carefully the results of comparative imaging studies of bile duct stones.

Adult↗
PubMed1985

Choledocholithiasis in infancy.

Three cases of choledocholithiasis presenting with obstructive jaundice in infancy are reported. Ultrasonography demonstrated a grossly dilated common bile duct in all three cases. It failed, however, to demonstrate the calculi that were situated at the distal end of the common duct. Percutaneous transhepatic cholangiography was valuable in one patient in outlining the biliary tract and in identifying the cause of the obstruction. Endoscopic retrograde cholangiopancreatography (ERCP) was employed in a child, aged three years, in whom it was possible to proceed to endoscopic sphincterotomy with clearance of the common duct. In small infants, transduodenal sphincteroplasty would appear to be the procedure of choice.

Cholangiography↗
PubMed1996

Combined laparoscopic and endoscopic approach in patients with cholelithiasis and choledocholithiasis.

BACKGROUND: The Optimal management of common bile duct stones in patients undergoing laparoscopic cholecystectomy remains controversial. METHODS: A prospective study was conducted in 145 of the 481 patients who had a preoperative endoscopic retrograde cholangiogram before their laparoscopic cholecystectomy. RESULTS: Endoscopic retrograde cholangiogram was successful in 138 patients (95%), and common duct calculi were found in 72 (50%) of them. Endoscopic sphincterotomy with ductal clearance was achieved in 62 of 67 patients during a mean of 1.4 sessions (range, 1 to 5). Five (3.4%) patients had complications after endoscopic intervention, all of which resolved uneventfully . Fourteen patients underwent laparoscopic common duct exploration, five had failed endoscopic extraction, five had their common duct stones left intentionally for laparoscopic intervention, and, in addition, four of the seven patients who had a failed endoscopic retrograde cholangiogram had stones identified by intraoperative cholangiogram. Ten of these 14 patients underwent a successful laparoscopic common duct exploration. Laparoscopic cholecystectomy was successfully completed in 134 of the 145 patients, and none had major intraoperative or postoperative complications. The mean postoperative stay was 2.7 days for those patients who underwent a successful laparoscopic procedure. The overall mean number of admissions for completing the treatment was 2.3. CONCLUSIONS: Combined laparoscopic and endoscopic approach is a viable option for patients with gallstones and choledocholithiasis.

Adult↗
PubMed2000

Prospective analysis of a scoring system to predict choledocholithiasis.

BACKGROUND: The management of choledocholithiasis in the laparoscopic era remains debatable. A common policy is to perform preoperative endoscopic retrograde cholangiopancreatography (ERCP) on patients suspected of having common bile duct (CBD) stones, using standard risk criteria. The aim of this study was to evaluate prospectively a scoring system designed to improve the accuracy of CBD stone prediction before laparoscopic cholecystectomy. METHODS: Known clinical, biochemical and radiological risk factors for CBD stones were analysed retrospectively in 233 patients. The presence (n = 77) or absence (n = 156) of CBD stones was determined by preoperative ERCP and/or laparoscopic cholangiography. Using multivariate analysis, the significant risk factors for CBD stones were identified and a new preoperative scoring system was developed. A score of 3 or more was taken as the cut-off point to suggest CBD stones and the need for preoperative ERCP. This scoring system was then tested prospectively in 211 consecutive patients with symptomatic gallstones requiring surgery. Patients whose bile ducts could not be demonstrated by ERCP or operative cholangiography were excluded. RESULTS: Fifty-five patients scored 3 or more (predicted ERCP rate of 29 per cent), of whom 23 (42 per cent) had proven CBD stones. Intraoperative cholangiography was successful in 87 per cent. Five patients (4 per cent) who scored less than 3 had small stones (less than 5 mm) demonstrated at operative cholangiography. The overall sensitivity and specificity of this scoring were 82 and 80 per cent respectively. CONCLUSION: Formal risk assessment of the presence of CBD stones using this scoring system is simple and may be used for preoperative selection of patients for biliary tract imaging by magnetic resonance cholangiography or ERCP.

Analysis of Variance↗
PubMed2002

Laparoscopic ultrasonography is a complement to cholangiography for the detection of choledocholithiasis at laparoscopic cholecystectomy.

BACKGROUND: Intraoperative cholangiography and laparoscopic ultrasonography are both used in the detection of common bile duct stones at laparoscopic cholecystectomy. The aim of this prospective study was to determine whether laparoscopic ultrasonography has an alternative or a complementary role with respect to cholangiography in achieving this end. METHODS: The biliary trees of 900 patients undergoing laparoscopic cholecystectomy were examined routinely by the two methods. The diagnostic power of each investigation and of the two techniques in combination was evaluated. The statistical non-random concordance between the two methods was also determined. RESULTS: Laparoscopic ultrasonography was performed in all 900 patients. Cholangiography was performed in 762 (85 per cent). The mean (range) duration was 9.8 (4-21) min for laparoscopic ultrasonography and 17.6 (7-42) min for cholangiography. For the detection of common bile duct stones, with a kappa coefficient of 0.57 (95 per cent confidence interval (c.i.) 0.43 to 0.71), the non-random concordance between the two methods was considered to be fair to good. The sensitivity of laparoscopic ultrasonography was 0.80 (95 per cent c.i. 0.65 to 0.91) and its specificity was 0.99 (95 per cent c.i. 0.98 to 1.00). The respective values for cholangiography were 0.75 (95 per cent c.i. 0.59 to 0.87) and 0.99 (95 per cent c.i. 0.98 to 1.00). The examinations combined had a sensitivity of 0.95 (95 per cent c.i. 0.86 to 0.99) and a specificity of 0.98 (95 per cent c.i. 0.96 to 1.00). CONCLUSION: Laparoscopic ultrasonography and intraoperative cholangiography are complementary, as the combination of both methods maximizes the intraoperative detection of choledocholithiasis.

Adult↗
PubMed1998

Ofuji's papuloerythroderma following choledocholithiasis with secondary sepsis: complete resolution with surgery.

We describe a case of Ofuji's papuloerythroderma (PE) in a 72-year-old man with biliary sepsis induced by choledocholithiasis. The PE disappeared completely after surgery with no relapse. This aetiology for PE does not appear to have been described previously, while its resolution after treatment of the primary process supports the idea that it may be a reactive disorder of multifactorial origin.

Aged↗
PubMed1977

Endoscopic choledochoduodenostomy for choledocholithiasis through choledochoduodenal fistula.

A new endoscopic method for treatment of choledocholithiasis in patients with choledochoduodenal fistula is described. In 2 patients with common bile duct stones a choledochoduodenostomy was performed by means of a diathermy snare. In both patients the calculi passed into the duodenum within some days. No complications occurred. It is concluded that the described technique may be helpful when surgery is contraindicated and when endoscopic papillotomy is difficult to perform.

Aged↗
PubMed1999

Foreign material as a cause of choledocholithiasis.

BACKGROUND AND STUDY AIMS: There are sporadic reports concerning foreign material as a cause of choledocholithiasis. Gallstones obtained endoscopically from the biliary duct were analyzed to determine their structure and the presence of foreign material. The possible correlation between foreign material in gallstones and clinical data was investigated. PATIENTS AND METHODS: Gallstones were examined qualitatively using a crystallographic analysis by X-ray powder diffraction, and the foreign material which was found was subjected to morphological analysis using polarization microscopy. Patients' clinical data were obtained from clinical records, physical examination and documentation. RESULTS: Out of a group of 54 patients, foreign material was found in CBD stones of six individuals (11.1%). Four of these patients were from the group who had undergone a previous cholecystectomy (29/54, 13.8%), and surgical suturing material was found in these four. On the other hand, in the group who had not undergone the operation, foreign material was found in two patients out of 25 (8%); in one case it was cellulose and in the other case the fibre was not identified. CONCLUSIONS: Foreign material can account for lithiasis in the biliary duct. In contrast to present reports in the literature, we have proved that this is possible even in patients without previous surgical intervention in the pancreatobiliary region.

Adult↗
PubMed1992

[Ultrasonic diagnosis of bile duct calculi. A prospective study regarding the effects and the objective and subjective factors on accuracy in choledocholithiasis].

The reliability and diagnostic sensitivity of the sonographic identification of bile duct concrements is mainly determined by the examiner's competence and the size of the concrements, and secondly also by the diameter or patency of the bile ducts. Basing on the records of 175 patients on whom choledocholithiasis had been performed, a prospective study (reference: concrement removal after ERCP) showed that the sensitivity of the method is almost twice as high with an experienced examiner than with a less experienced physician (80% vs. 47%). In 231 other cases with extrahepatically conditioned cholestasis we found a 93% specificity of sonography in respect of excluding the presence of concrements. 93% of the concrements that were bigger than 10 mm were definitely diagnosed via sonography (71% sensitivity in case of concrements < 10 mm). If the proof of presence of concrements is differentiated according to bile duct width, it is seen that 85% of all concrements were visualised if the width of the ductus choledochus was > or = 8 mm and 71% in case of a width < 8 mm. The results of the study justify the use of sonography as a primary method in the diagnosis of concrements of the bile ducts; under certain conditions it is also possible to exclude the presence of stones. If findings do not agree with the clinical pattern of findings, or if the bile ducts cannot be visualised properly, diagnostic ERCP is indicated.

Ampulla of Vater↗
PubMed1987

[Sonographic diagnosis of bile duct calculi. Results of a prospective study of 222 cases of choledocholithiasis].

To evaluate sonographic accuracy in the diagnosis of choledochal calculi 490 patients with cholestasis were examined prospectively with real-time scanner before ERCP or surgery. Ultrasound detected duct stones in 177 of 222 patients (sensibility 80%) and their absence in 242 of 268 (specificity 90%). Dilated extrahepatic bile ducts were demonstrated via ultrasound in 84% of cases with choledocholithiasis, dilated intrahepatic bile ducts in 57%. Intestinal gas obscuring the distal common duct was the most important factor limiting the ability of ultrasound to detect duct stones.

Adolescent↗
PubMed1987

Evaluation of a combined percutaneous-endoscopic procedure for the treatment of choledocholithiasis and benign papillary stenosis.

In 19 patients suffering from choledocholithiasis or papillary stenosis, retrograde cholangiography or sphincterotomy failed because of anatomic abnormalities. In such cases, sphincterotomy was then performed with the assistance of a percutaneous catheter. Two complications were observed: moderate bleeding from the transhepatic drain, and a retroperitoneal perforation needing surgery. This combined procedure is very efficient, but gives rise to complications of both the transhepatic and endoscopic routes.

Aged↗
PubMed2001

The rendezvous technique for the treatment of choledocholithiasis.

BACKGROUND: The rendezvous technique combines endoscopy with percutaneous transhepatic cholangiography to facilitate cannulation of the bile duct when previous attempts have failed. METHODS: Over a 7-year period, a total of 1753 ERCPs were performed. Twelve of these patients with a diagnosis of choledocholithiasis were poor candidates for surgery. Percutaneous transhepatic cholangiography as well as ERCP with precut papillotomy failed to resolve biliary obstruction. In a further 2 cases the percutaneous approach was used by means of a T-tube positioned at a prior cholecystectomy. OBSERVATIONS: The combined procedure was successful in 13 patients (93%). It was unsuccessful in 1 patient because of a stone lodged distally near the papilla. There was only 1 complication (7%), a retroperitoneal perforation that occurred during papillotomy; no mortality was directly attributable to the technique. CONCLUSIONS: The rendezvous technique is recommended for patients who are not eligible for surgery when ERCP is unsuccessful and when it is impossible to resolve biliary obstruction by percutaneous transhepatic cholangiography.

Aged↗
PubMed1992

Alternative management of choledocholithiasis.

This paper is presented to clarify the role of ERCP in conjunction with laparoscopic cholecystectomy. As the field of surgery moves more toward less invasive procedures, our management schemata may also need revision. With the popularity of laparoscopic cholecystectomy came a large increase in the number of patients treated with cholelithiasis, and therefore an increase in patients with choledocholithiasis. The authors believe that treatment options exist to avoid open common bile duct procedure in most cases.

Adult↗
PubMed1995

Management of choledocholithiasis during pregnancy: a new protocol in the laparoscopic era.

The management of symptomatic cholelithiasis during pregnancy remains a serious and difficult problem. This condition may be further complicated by the presence of common bile duct stones (CBDS). Two cases of CBDS in pregnancy are presented. During the period from August 1990 to June 1994, 1127 consecutive patients underwent LC by a single surgical team. Two (0.2%) of these patients were pregnant and both were found to have choledocholithiasis. One patient's stones were lavaged into the duodenum via the cystic duct and the other patient had transcystic choledochoscopy and transcystic duct tube drainage. The patients were discharged from the hospital on postoperative days 4 and 6, respectively. There were no complications and both successfully carried their pregnancies to term. Laparoscopic cholecystectomy (LC) with transcystic common bile duct exploration (TCDE) was advantageous in both patients. Neither patient required an abdominal incision or choledochotomy. Laparoscopic TCDE with or without cystic tube drainage is a viable option in the management of CBDS in the pregnant patient.

Adult↗
PubMed1991

Choledocholithiasis. Endoscopic sphincterotomy or common bile duct exploration.

A prospective randomized trial was conducted of preoperative endoscopic sphincterotomy and surgery (ES&S) or surgery alone (SA) in 52 patients with cholecystolithiasis and choledocholithiasis that were candidates for elective surgery. After ES&S 65% of patients were stone free. Eighty-eight per cent of patients with SA were stone free after surgery (p less than 0.05). Three patients in each group had residual stones at the completion of the operation. Five of these six had more than 20 common bile duct (CBD) stones. There was one episode of major hemorrhage in a patient in each group and no deaths. Costs were essentially equal for the individual patient with a successful ES as compared to SA. Societal costs of a program of preoperative endoscopic retrograde cholangiopancreatography and ES would be higher because of the cost of screening for patients with CBD stones. These results do not support preoperative ES as a technique for clearance of the CBD of stones on the basis of efficacy, morbidity rate, or cost.

Adult↗
PubMedDate not supplied

Calcified intrahepatic portal vein thrombus: distinction from intrahepatic choledocholithiasis.

In a case of calcified intrahepatic portal vein thrombus CT demonstrated a branching calcified intrahepatic mass with peripheral enhancement following dynamic bolus contrast medium administration. The distinction from intrahepatic choledocholithiasis was made with normal cholangiography. Calcified portal vein thrombus should be considered an unusual cause of branching calcified intrahepatic mass on CT.

Adult↗