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PubMed1980

[Choledocholithiasis after cholecystectomy].

Concrements were found in the ducts of 172 patients subjected to secondary surgical interventions on bile ducts. The detailed analysis of the data failed to answer the question whether the stones could be formed immediately in the ducts without such conditions as a mechanical obstacle for the outflow of bile, the presence of foreign bodies and a big stump of the cystic duct. Such a formation of stones can take place in very few cases. The authors have shown that control cholangiography and especially choledochoscopy can reduce the danger to leave the stones in the ducts, but does not eliminate the danger completely. Nevertheless they think that now it is possible to lessen the indications for biliodigestive anastomoses in choledocholithiasis since the retained stones can be revealed within the first days after surgery and, as a rule, removed with instruments or by other methods using the drainage left in the ducts.

Cholecystectomy↗
PubMedDate not supplied

[The diagnostic and therapeutic unity of endoscopic retrograde cholangiopancreatography in patients with a diagnosis of choledocholithiasis and its complications].

Reviewing the records of 60 patients admitted with clinical diagnosis of common duct stone, we demonstrated that the symptoms and the biochemical liver tests were predictive of choledocholithiasis only 50% of the time. The sensitivity for the ultrasound was 42%. The ERCP diagnosed pancreatic or biliary pathology in over 90% of the patients. Through endoscopic sphincterotomy, the ERCP prevented the surgical exploration of the common bile duct in 93% of the patients, and did not aggravate the clinical picture in the group with acute pancreatitis. The sequence of ERCP--laparoscopic cholecystectomy decreased the hospital days and has emerged as the treatment of choice for the patients with cholelithiasis and suspected common duct stone.

Adolescent↗
PubMed1994

[Surgical treatment of choledocholithiasis complicated by obstructive jaundice].

Cholecystectomy was conducted in 820 patients. In 115 (14,0%) of them it was combined with interventions performed on extrahepatic biliary ducts for choledocholithiasis and obstructive jaundice. Patients aged from 20 to 90 years. There were 30 men and 85 women. Choledocholithotomy with subsequent inspection of the common biliary duct (CBD) distal portion was considered as the operation of choice. Operation was concluded with external drainage of CBD, choledochoduodenal anastomosis formation and transduodenal papillosphincterotomy conduction. Of the patients operated on 6 (5,2%) have died.

Adult↗
PubMed1994

[Computer prognostication in surgery of choledocholithiasis].

The automatized value of treatment results and postoperative period course was done according to special programs in 218 patients with choledocholithiasis using the united computer system. Integral risk factors and four regressional patterns of postoperative period course were obtained using the factor analysis. Prognosis was quite right in 87,5-97,5% of patients.

Adult↗
PubMed1994

[Surgical treatment of residual choledocholithiasis].

The results of studying of the treatment effectiveness in 30 patients with residual choledocholithiasis (RC) were generalized. In 131 (23.8%) of patients simultaneously with endoscopic papillosphincterotomy (EPST) various endobiliary manipulations on biliary ducts were conducted, in 21 (16.2%) of them--nasobiliary drainage, in 14 (10.8%)--mechanical lithotripsy, in 6 (4.5%)--lithotripsy plus nasobiliary drainage. Great significance in RC diagnosis have the methods of direct contrasting of biliary ducts. The authors characterize the partial, subtotal and total EPST according to the length of major duodenal papilla incision. After papillosphincterotomy in 97 (75%) of patients the concrements were mechanically removed with maximal diameter 2.5 cm. In 10.8% of patients complications occurred. All of the patients are alive.

Adult↗
PubMed1995

[Laparoscopic therapy of choledocholithiasis].

In the period November 1991 to October 1993 altogether 418 patients underwent laparoscopic cholecystectomy in our unit. Routine intraoperative cholangiography, a prerequisite for diagnosing choledocholithiasis, was successful in 99.3% of cases. 38 patients were found to have common bile duct calculi and their management and follow up are reported in this study. In 36 cases stones were successfully eliminated by means of the laparoscopic procedure, via the cystic duct in 22 cases and by choledochotomy in 14 cases. One patient required postoperative endoscopic papillotomy, and in the remaining case surgical management was changed to classical laparotomy and open choledochotomy. Postoperative complications occurred in five cases. One patient suffering from bacterial peritonitis underwent laparotomy on the 9th postoperative day, another with postoperative bleeding from the cystic artery was relaparoscopied on the same day as the minimal invasive procedure. One patient developed a liver abscess three weeks after operation, requiring drainage with the aid of ultrasound. A superficial wound infection in one patient and biliary leakage after removal of the T-tube in another patient both healed spontaneously. Our results are similar to those obtained with other therapeutic concepts. Because the papilla of Vater remains intract in minimal invasive surgery, which causes relatively little stress to the patient, as well as considering the economic advantages of a single-step procedure, this management strategy can be recommended as a valuable alternative procedure.

Cholecystectomy, Laparoscopic↗
PubMed1994

[Does laparoscopy influence the treatment of choledocholithiasis?].

Operative common bile duct exploration, performed in conjunction with cholecystectomy, used to be considered the treatment of choice for choledocholithiasis in the presence of an intact gallbladder. The advent of laparoscopic cholecystectomy (LC) has affected the management of common bile duct stones. More emphasis is placed on preoperative intravenous cholangiography (IVC) and endoscopic retrograde cholangiography (ERC) with endoscopic papillotomy (EP) either just before or soon after laparoscopic surgery. This involves the patient in an additional procedure with its associated risks. Single-stage treatment of biliary lithiasis, i.e. LC and laparoscopic common bile duct exploration (LCDE) appears preferable to two-stage treatment, especially when the ampulla of Vater can be preserved. 550 consecutive patients with LC are reviewed. IVC with tomography was performed in 341 of these patients without complications and with a sensitivity of 75% and a specificity of 99%. The procedure failed in 5.6% due to poor quality imaging, and was contraindicated in 21 patients. With increasing laparoscopic experience, intraoperative cholangiography (IOC) was adopted and has been used routinely since November 1992. IOC was successful in 204 of 209 attempts (97.6%) with a sensitivity of 95% and a specificity of 100%. The mean operation time for IOC was 10 minutes. Unsuspected bile duct stones were found in 6% of instances. IOC demonstrated one choledochotomy (0.18% of all LC), thus preventing transsection of the duct. 47 patients (8.5%) had common duct stones. 29 (62%) were treated by ERC and EP, while 18 (38%) underwent LCDE. Successful clearance was achieved endoscopically in 94% and laparoscopically in 82% of the attempts.(ABSTRACT TRUNCATED AT 250 WORDS)

Cholangiography↗
PubMed1994

[Biliary pseudocyst as a rare complication of choledocholithiasis].

Biliary pseudocysts, so-called biliomas are reported to be an extreme rarity and mostly arising posttraumatic. We report on a case of symptomatic choledocholithiasis 7 years after cholecystectomy. The course was complicated by formation of a biliary pseudocyst. The 71-year-old, septic patient could not be operated because of pulmonal and cardiac high risks. He could be treated successfully by conservative procedure via endoscopic papillotomy, stone extraction and percutaneous, sonographic controlled drainage of the biliary pseudocyst.

Aged↗
PubMed1993

[A rational procedure for the treatment of patients with chronic calculous cholecystitis complicated by choledocholithiasis].

The results of surgical treatment of 156 patients with chronic calculous cholecystitis complicated by choledocholithiasis have been analysed. In 62 patients, cholecystectomy in combination with choledocholithotomy was performed. Ninety four patients underwent additional drainage operations on the terminal common bile duct. Endoscopic papillosphincterotomy was performed in 90% of cases, other drainage interventions (choledochoduodenostomy and transduodenal papillosphincterotomy)--in 10%.

Cholecystectomy↗
PubMed1993

[Transduodenal papillosphincteroplasty in the treatment of choledocholithiasis and benign stenosis of the terminal choledochus and papilla Vateri].

The article contains data form the surgical treatment of 297 patients with choledocholithiasis and benign stenosis of choledochus terminal and papilla Vateri, treated in the Academy of Medicine-General and Operative Surgery within the period 1983-1992. The data relate to 59 patients with biliodigestive anastomosis, 114 patients with choledochotomy and T-drainage (Kehr drainage) and 124 patients with transduodenal papillosphincteroplastica. The postoperative lethality in the general series of patients was 3.03%, for the patients with transduodenal papillosphincteroplastica--0.8%. The serious complications in the postoperative period in the cases of papillosphincteroplastica represent 0%, while the excellent and very good results in the distant period--95.16%. The authors state the precise moments of the surgical techniques in the cases of transduodenal papillosphincteroplastica and their importance for the postoperative results. The authors specify the indications and the contraindications for carrying out the different surgical and endoscopic procedures.

Adult↗
PubMed1993

[A case of spontaneous biloma accompanied with incarcerated choledocholithiasis].

A 55-year-old man was admitted with abdominal pain and nausea. CT-scan and US showed no abnormal findings. On the 5th hospital day, a large mass was palpable on the upper abdomen, and CT-scan (7th hospital day) demonstrated a large, cystic mass below the left lobe. A thoracentesis under ultrasound guidance obtained bile-stained fluid. PTCD revealed choledocholithiasis and severe dilatation of the common bile duct and the left branch. After conservative treatment, cholecystectomy and choledocholithotomy were performed. Biloma occurred mainly traumatically or iatrogenically. This case had a spontaneous biloma, and only 11 cases have been previously reported as spontaneous biloma in Japan.

Bile↗
PubMed1993

[Choledocholithiasis following cholecystectomy: what is the real effectiveness of endoscopic sphincterotomy?].

AIM: To assess real efficacy of endoscopic sphincterotomy in the setting of postcholecistectomy choledocolitiasis (i.e., without excluding for analysis any patient referred for the procedures) traditionally the evaluation has been done after excluding those cases in which the procedure failed or was not attempted. DESIGN: Retrospective analysis of a series of cholecystectomized patients with choledocolithiasis. Patients were included for analysis on an "intention to treat" basis, without excluding cases in which the procedure either was not attempted or failed. RESULTS: Out of 122 patients (47.1%) with a firm diagnosis of choledocholithiasis, endoscopic sphincterotomy was performed in 108 (88.5%); in the remaining 13 (10.7%), it was not attempted due to various reasons (among other, five cases of unsuccessful diagnostic cholangiography). In one patient, with a previous surgical sphincteroplasty, calculi were directly extracted. On the whole, stone extraction/expulsion was achieved in 92 cases (including the one patient with previous surgical sphincteroplasty), what represents a success rate of 75.4% on 122 cholecistectomized patients with known choledocolitiasis. Morbidity and mortality reached 9% and 1%, respectively. CONCLUSIONS: If each referred patient is included for analysis of the results of endoscopic sphincterotomy for postcholecistectomy choledocolithiasis (independently of technical success), the therapeutic yield of this procedure lowers significantly compared with the usual estimations.

Adolescent↗
PubMed1993

Long term results of surgical sphincterotomy in the treatment of choledocholithiasis.

The present article analyzes the indications for sphincterotomy in the Surgical Department of the University of Murcia, postoperative morbidity and mortality and the long term clinical situation of the patient after a follow-up period averaging 5.8 years. During a ten year period, a total of 2,610 patients underwent operation for biliary lithiasis, with exploratory choledochotomy indicated in 591 (22.6 percent). Surgical exploration of the bile duct finished with sphincterotomy in 135 (22.9 percent); 52 percent of these patients were less than 60 years old. The most frequent preoperative diagnosis was choledocholithiasis (33.3 percent) and cholelithiasis with crises of acute pancreatitis (30.3 percent). If we divide the ten years of the study into two five year periods, we noted a statistically significant decrease (p < 0.001) in the percentage of sphincterotomies compared with the number of choledochotomies performed during the second period. The rate of intra-abdominal complications was 5.1 percent; four intra-abdominal abscesses, one hemorrhaging at the level of the sphincterotomy and two instances of postoperative pancreatitis. Mortality in the series was 1.4 percent (two patients)--one with postoperative pancreatitis that developed torpidly and one with pulmonary embolism. Six years after the operation, 72.9 percent of the patients are still asymptomatic and the remaining patients have some type of symptoms--15.8 percent presented with dyspeptic syndrome; 2.0 percent had crises of colicky pain, and 5.9 percent required hospital admission for cholangitis. All of the patients with symptoms underwent endoscopy and ultrasonographic exploration of the bile duct. There were no pathologic findings in the biliary tree of patients who had dyspeptic syndrome or colicky pain, and all of the patients with cholangitis had a papillary stenosis and required endoscopic sphincterotomy or reoperation.

Female↗
PubMed1993

[Preoperative ERCP and laparoscopic cholecystectomy for treatment of choledocholithiasis].

Out of 110 patients suffering from gallstone-related symptoms, 21 underwent ERCP prior to laparoscopic cholecystectomy. Indications for this combined treatment were laboratory signs of cholestasis (36%), pancreatitis (29%), pathological IVC (18%), sonographic evidence for bile duct dilatation (10%) and cholangitis (7%). Local and general complications were not increased neither intraoperatively nor postoperatively. Median duration of postoperative hospital stay was four days for ERCP-treated patients as compared to three days for patients subjected to laparoscopic cholecystectomy only. In summary treatment of choledocholithiasis by a combination of preoperative ERCP and laparoscopic cholecystectomy offers the following advantages: high patient comfort, low incidence of complications and short hospitalization compares favourably with conventional common bile duct exploration.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1993

The role of endoscopic retrograde cholangiopancreatography: sphincterotomy versus common bile duct exploration as a primary technique in the management of choledocholithiasis.

253 patients underwent diagnostic or therapeutic intervention for a presumed diagnosis of choledocholithiasis. In 104 (mean age, 60 years) the diagnosis was confirmed by endoscopic retrograde cholangiopancreatography (ERCP) or common bile duct exploration (CBDE). Of this group, 70 patients first underwent a total of 102 attempts at endoscopic sphincterotomy (ERCP-S). Success (clearing the common duct of stones) was achieved in 43 patients (61%), though an average of 1.5 ERCP-S/patient was required (maximum of four per patient). Of the 27 in whom ERCP-S failed, 20 went on to CBDE, which was successful in 18. Significant morbidity occurred in 12 (17%) ERCP-S patients, including hemorrhage. There were no deaths. Of the 34 patients who first underwent CBDE, 30 were cleared of common duct stones (88%). ERCP-S was subsequently employed to retrieve retained stones in three patients. Significant morbidity was documented in three (9%). No patients required perioperative blood transfusion. There were no deaths. While there is, as expected, a lower initial success rate with ERCP-S than with CBDE, the fact that ERCP-S is a less invasive procedure than is CBDE justifies its preferential utilization. However, patients must be informed that successful ERCP-S may require multiple visits to the endoscopy suite. Furthermore, the morbid consequences of ERCP-S, particularly hemorrhage, cannot be understated.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1977

[Acute cholecystitis in choledocholithiasis and stricture of the ampulla of Vater].

The work is based on the examination of 106 patients, operated in the clinic for acute cholecystitis associated with choledocholithiasis and strictures of Vater's papilla. The operation of choice is a removal of pathologically changed gallbladder, elimination of the cause of cholestasis with restoration of bile passage in the bowel. The technic of choledochoduodenostomy adopted in the clinic is described. The immediate mortality was observed in 2.8%. Choledochoduodenostomy yielded good results in 81.1%, external drainage -- in 70.6%.

Acute Disease↗
PubMed1995

[Treatment of cholecysto-choledocholithiasis in the present era of minimally invasive laparoscopic surgery].

The authors try to contribute to the solution of the problem of cholecystolithiasis associated with choledocholithiasis. Nowadays in the era when choledochilithiasis is treated by low-invasion methods the solution has a different character. The majority of gallstones is symptomatic, their verification and removal by the endoscopic route is not associated with major problems. Concrements not detected during the perioperative period and not detected by diagnostic methods may cause various postoperative difficulties. The authors' experience is based on 302 laparoscopic cholecystectomies performed in the course of 14 months. They made cholangiographic examinations in 54 of the operated patients. This number comprised 21 where the examination was made before the operation, 18 during the operation and in 5 it was made during the postoperative period. In 20 patients (37.03%) the cholangiographic finding was positive. Due to intensive collaboration with the endoscopic centre, when using the method of therapeutic splitting und per operative cholangiography in indicated cases, they were able to reduce the risk of missed concrements to 0.33%.

Adult↗
PubMed1996

[Laparoscopic therapy of choledocholithiasis].

The introduction of laparoscopic cholecystectomy has led to controversial discussions about the proceeding in case of coincident common bile duct stones. In our unit choledocholithiasis has been treated laparoscopically since November 1991. Basic requirement has been a routine intraoperative cholangiography. 67 patients with common bile duct stones were treated until January 1995. All patients underwent a follow up and the results were compared to other concepts. In 40 cases common bile duct stones were eliminated via cystic duct and in 27 cases by choledochotomy. The choledochus was drained routinely for postoperative x-ray control. In 9 cases we found residual concrements: 7 patients required postoperative endoscopic papillotomy and in 2 cases the calculi where eliminated with a dormia basket introduced via drainage tube. In one case surgical management was changed to laparotomy. Postoperative complications occurred in 8 cases. One patient suffering from bacterial peritonitis underwent laparotomy on the 9th postoperative day; one with bleeding from the cystic artery was treated by relaparoscopy. One patient developed a liver abscess and two patients a bilioma requiring ultrasound guided drainage. A superficial wound infection in one patient and a biliary leakage after removal of the drainage in two patients healed spontaneously. Due to an intact papilla with less stress to the patient, as well as a complication rate comparable with other published therapeutic concepts, this strategy can be recommended as a valuable alternative procedure.

Cholangiography↗