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PubMed2007

Asymptomatic cholelithiasis in children with sickle cell disease: early or delayed cholecystectomy?

SUMMARY BACKGROUND DATA: Our study aimed to evaluate the role of elective laparoscopic cholecystectomy (LC) in children with sickle cell disease (SCD) and asymptomatic cholelithiasis and, furthermore, to determine whether the outcome is related to the operation timing. METHODS: The records of 30 children with SCD diagnosed with cholelithiasis from June 1995 to September 2005 were retraspectively reviewed. All 30 children were asymptomatic at the time of the first visit, and an elective LC was proposed to all of them. The operation was accepted in the period of study by 16 children and refused by 14. During medical observation, 10 of the 14 children who refused surgery were admitted for severe biliary colics. Acute cholecystitis was diagnosed by abdominal ultrasound in 3 cases and in 1 case choledocholithiasis, ultrasonographically suspected, was confirmed by magnetic resonance cholangiopancreatography (MRCP) and treated during endoscopic retrograde cholangiopancreatography (ERCP). All children, emergency admitted, underwent LC after the onset of symptoms. The patients were divided up into 2 groups (A: asymptomatic; B: symptomatic) depending on clinical presentation and operation timing and the respective outcomes were compared. RESULTS: Elective LC in asymptomatic children (group A) is safe with no major complications reported. During medical observation in children who refused elective surgery (group B), 6 biliary colics, 3 acute cholecystitis, and 1 choledocholithiasis were observed. Three sickle cell crises occurred in symptomatic children during biliary colics. The correlation between cholecystectomy performed in asymptomatic children (group A) and cholecystectomy performed in symptomatic children (group B) showed significant differences in the outcome. Morbidity rate and postoperative stay increased when children with SCD underwent emergency LC. CONCLUSIONS: Elective LC should be the gold standard in children with SCD and asymptomatic cholelithiasis to prevent the potential complications of biliary colics, acute cholecystitis, and choledocholithiasis, which lead to major risks, discomfort, and longer hospital stay.

Adolescent↗
PubMed2005

Extrahepatic portal venous obstruction and obstructive jaundice: approach to management.

BACKGROUND: Patients with long-standing extrahepatic portal venous obstruction (EHPVO) develop extensive collaterals in the hepatoduodenal ligament as a result of enlargement of the periportal veins. These patients are also prone to develop obstructive jaundice as a result of strictures and/or choledocholithiasis. Surgical management of obstructive jaundice in such patients becomes difficult in the presence of these collaterals. AIM: To review the approach to management of patients with EHPVO and obstructive jaundice. METHODS: Retrospective review of patients with EHPVO and obstructive jaundice requiring surgical and/or endoscopic management between 1992 and 2002. RESULTS: Thirteen patients (nine males, aged 12-50 years) with EHPVO and obstructive jaundice were evaluated. No patient had underlying cirrhosis or hepatocellular carcinoma. Five patients (group A) had biliary stricture; three (group B) had choledocholithiasis; and five (group C) had biliary stricture with choledocholithiasis. Primary surgical management was performed in group A (portosystemic shunt in four-strictures resolved in three; hepaticojejunostomy in one). In group B (n = 3) endoscopic stone extraction was successful in two patients. One patient underwent staged procedure (portosystemic shunt followed by biliary surgery). In group C, initial endoscopic management failed in four patients in whom it was attempted. All five patients thereafter underwent surgery (staged procedure, one; choledochoduodenostomy, one; devascularization, one; abandoned, two). Repeat postoperative endoscopic management was successful in two of the group C patients. Overall (group B and C), massive intraoperative hemorrhage occurred in three patients (one died). Postoperative hemorrhage occurred in one patient. CONCLUSION: In patients with EHPVO and obstructive jaundice, primary biliary tract surgery has significant morbidity and mortality. Endoscopic management should be the preferred modality. In patients with endoscopic failure, a staged procedure (portosystemic shunt followed by biliary surgery) should be preferred. Strictures alone may resolve after a portosystemic shunt. Endoscopic stenting may be required as an adjunct.

Adolescent↗
PubMed2004

Feasibility of laparoscopic common bile duct exploration in a rural centre.

BACKGROUND: Laparoscopic common bile duct exploration has emerged as a preferred option for the management of choledocholithiasis. The present study sought to review the feasibility of this technique in a rural centre. METHODS: A comprehensive retrospective review was undertaken of all patients who underwent surgical treatment of biliary calculi in Lismore, NSW (Australia), between January 1996 and December 2002. RESULTS: During the study period, 1567 consecutive patients underwent laparoscopic cholecystectomy, of whom 82 (5.2%) had choledocholithiasis identified at intraoperative cholangiography. A total of 86 laparoscopic common bile duct explorations were undertaken in these patients, 37 (43%) via a transcystic approach, and 49 (57%) via a laparoscopic choledochotomy. All common bile duct calculi were successfully removed in 78 cases, representing an overall duct clearance rate of 90.7%. Complications were noted in seven patients, a morbidity rate of 8.5%. Median operative time for the procedure over the study period was 173 min. Median hospital stay was 6 days for all patients. CONCLUSIONS: Laparoscopic common bile duct exploration can be successfully undertaken in a rural setting by general surgeons who have appropriate laparoscopic experience, and should be the procedure of choice for the management of choledocholithiasis in these patients. It should not be restricted to specialized surgical departments in major referral centres.

Cholecystectomy, Laparoscopic↗
PubMed1981

Endoscopic sphincterotomy in high-risk patients with biliary tract disease.

Endoscopic sphincterotomy was performed in 53 patients with biliary tract disease who were considered to be at high risk from conventional surgical procedures. Forty-five patients had choledocholithiasis, while eight had miscellaneous disorders including carcinoma, stenosis of the papilla, and postoperative biliary fistulae. Forty-three of 45 patients with choledocholithiasis have been free of symptoms since the procedure, and most have had repeat retrograde cholangiography confirming the absence of bile duct-stones. Endoscopic sphincterotomy is a safe and effective procedure in selected high-risk patients, particularly those with choledocholithiasis after cholecystectomy.

Adult↗
PubMed2001

Value of magnetic resonance cholangiography in the preoperative diagnosis of common bile duct stones.

OBJECTIVE: The aim of this study was to assess the performance of magnetic resonance cholangiography (MRC) in the preoperative diagnosis of choledocholithiasis. METHODS: A total of 147 consecutive patients underwent MRC for clinical and biological signs of common bile duct stones. ERCP was then carried out in 101 patients in whom there was a past history of cholecystectomy. The remaining 46 patients without a past history of biliary surgery underwent cholecystectomy and intraoperative cholangiography (IOC). The diagnosis obtained by MRC was compared with the final diagnosis established after endoscopic or surgical removal of calculi. RESULTS: A total of 113 patients had choledocholithiasis (single or multiple, including 15 cases of microlithiasis). There were no false-positive results with MRC. The false-negative results were caused mainly by small stones <3 mm in diameter, and to a lesser extent, cholangitis. Overall, the sensitivity was 93% and the specificity 100% for MRC in detecting common bile duct stones. The sensitivity and specificity of ERCP were respectively 94% and 100%, versus 93.5% and 93.3% for IOC. There was no statistically significant difference, however, between MRC and the other techniques. CONCLUSION: MRC is a key technique in the preoperative diagnosis of choledocholithiasis. Its diagnostic value is comparable to ERCP, but it appears to be more specific than IOC. Nevertheless, its diagnostic capability remains limited in cases of microlithiasis and cholangitis.

Cholangiography↗
PubMed2002

Risk factors predictive of late complications after endoscopic sphincterotomy for bile duct stones: long-term (more than 10 years) follow-up study.

OBJECTIVE: Widespread use of laparoscopic cholecystectomy has extended the indications for endoscopic sphincterotomy (ES) to young patients with choledocholithiasis; however, long-term results of ES and risk factors for late complications are largely unknown. METHODS: Between 1977 and 1990, 145 patients aged 60 yr or younger underwent ES for choledocholithiasis. Long-term outcomes of ES were investigated in the year 2000, and prognostic factors for late complications were multivariately analyzed. RESULTS: Long-term information was available in 135 cases (93.1%), with a median overall follow-up duration of 14.5 yr (range, 6.5-22.3 yr). There were neither biliary malignancies nor deaths attributable to biliary disease. Sixteen patients (11.9%) developed late complications, including choledochal complications (stone recurrence and/or cholangitis; 14 patients) and acute cholecystitis (two of 32 patients with the gallbladder in situ). Multivariate analysis identified two independent risk factors for choledochal complications: bile duct diameter > or = 15 mm and brown pigment stones at the initial ES. Choledochal complications were endoscopically manageable. All recurrent stones were brown pigment stones. CONCLUSIONS: Approximately 12% of patients develop late complications after ES, but retreatment with ERCP is effective. ES is a reasonable alternative even in young patients with choledocholithiasis. Careful follow-up is necessary, however, particularly for patients with a dilated bile duct or brown pigment stones.

Adult↗
PubMed2003

Safety of extension of a previous endoscopic sphincterotomy: a prospective study.

OBJECTIVES: Data in the literature regarding complication risks after the extension of a previous endoscopic biliary sphincterotomy (repeat endoscopic biliary sphincterotomy) are limited and controversial. To explore this issue, we prospectively studied complications after repeat sphincterotomy and compared them with those of biliary endoscopic sphincterotomy in consecutive patients with choledocholithiasis. METHODS: A total of 250 patients underwent endoscopic biliary sphincterotomy and 81 underwent extension of a previous one. All patients had choledocholithiasis and were enrolled using specific criteria, excluding parameters predisposing to increased postsphincterotomy complications. RESULTS: The overall complication rate was 2.46% in the repeat sphincterotomy and 8.4% in the sphincterotomy group (p > 0.05). Complications for the repeat sphincterotomy and initial sphincterotomy groups, respectively, were as follows: bleeding, 2.46% and 2.8%; pancreatitis, 0% and 4.8% (p < 0.05); cholangitis, 0% and 0.4%; perforation, 0% and 0.4%; and hyperamylasemia, 3.7% and 12.8% (p < 0.05). There were no deaths. Bleeding episodes in the former group occurred when repeat sphincterotomy was performed early after the primary one. CONCLUSIONS: Repeat sphincterotomy is a safe technique for the treatment of patients with choledocholithiasis and seems to be as safe as initial sphincterotomy. It is not associated with increased hemorrhage risk. There is a trend toward a higher risk of hemorrhage when repeat sphincterotomy is performed early. Repeat sphincterotomy is safer than the initial sphincterotomy with respect to pancreatic complications.

Adult↗
PubMed1987

Migration of gall stones.

The factors influencing the migration of gall stones are ill understood. Altogether 331 patients undergoing cholecystectomy were studied prospectively. The diameters of the cystic and common bile ducts and of stones in the gall bladder and bile ducts were measured. Increasing pressure was applied to the freshly excised gall bladder in an attempt to evacuate stones through the cystic duct. Stones passed in 33 (60.0%) of patients with choledocholithiasis, 45 (67.2%) of patients with pancreatitis, and 7 (3.2%) of patients without either pancreatitis or choledocholithiasis. Stones migrated in 6 (3.0%) who had a normal cystic duct diameter (less than or equal to 4 mm) and in 46 (32.5%) with a duct over 4 mm diameter. Common bile duct stones were often larger than the diameter of the cystic duct and when reintroduced into the gall bladder would not migrate. The passage of debris (less than or equal to 1 mm) through the cystic duct bore no relation to the presence or absence of choledocholithiasis or a dilated cystic duct. Small stones (1-4 mm diameter) must migrate to initiate and facilitate further migration; some must increase in size in the common bile duct. Increased biliary pressure consequently dilates the duct system retrogradely, allowing larger stones to follow. Patients at risk of stone migration and thereby pancreatitis and jaundice have large ducts that can be detected by ultrasound assessment.

Cholecystectomy↗
PubMed1996

Changes of bile duct mucosa after choledochoduodenostomy in rats.

This study investigated the changes of bile duct mucosa in rats after choledochoduodenostomy. Wistar rats were divided into three groups: group I (n = 6) was treated with sham operation as control; group II (n = 10) was treated with common bile duct ligation without choledochoduodenostomy, and group III (n = 12) had both common bile duct ligation and choledochoduodenostomy creation 4 days after common bile duct ligation. From our observations, retrograde induced cholangitis due to enteric reflux into the common bile duct is the possible cause of chronic inflammation after choledochuduodenostomy. At the end of the study, Choledocholithiasis developed in 5 of 12 rats. Severe dysplasia was present in the bile duct mucosa in 6 of 12 rats in group III, but not in group I or II. A technique for silver staining of nucleolar organizing regions (AgNOR) was applied. This technique demonstrated differences in AgNOR counts between normal mucosa and dysplasia. Under AgNOR stain, the number of AgNOR was significantly greater than in the normal or benign counterparts and gradually increased from the normal bile duct mucosa group to the severe dysplasia group (group I 2.1 +/- 0.8, group II 3.2 +/- 1.0, group III 5.3 +/- 1.1). All of these observations suggest that 'sump syndrome' and bile stasis could occur after choledochoduodenostomy in rats and can result in chronic inflammation of the bile duct. It has been well established that calcium bilirubinate is the major type of choledocholithiasis in Orientals. beta-Glucuronidase from bacteria, such as Escherichia coli present in the biliary tree, hydrolyzes bilirubin diglucuronide to bilirubin. Bilirubin combines with calcium in the bile flow to form calcium bilirubinate. Bacterial infection plays a key role in calcium bilirubinate stone formation. Since choledochoduodenostomy did increase reflux cholangitis, and bacterial infection would increase mucin overproduction, bile deconjugation and eventually new calcium bilirubinate stones would be formed. The dysplastic changes in the bile duct mucosa could possibly be related to the prolonged exposure to the biochemically altered infected bile. Thus choledochoduodenostomy might not be the perfect choice in treating calcium bilirubinate choledocholithiasis in Orientals.

Animals↗
PubMed2006

MRCP compared to diagnostic ERCP for diagnosis when biliary obstruction is suspected: a systematic review.

BACKGROUND: Magnetic resonance cholangiopancreatography (MRCP) is an alternative to diagnostic endoscopic retrograde cholangiopancreatography (ERCP) for investigating biliary obstruction. The use of MRCP, a non-invasive procedure, may prevent the use of unnecessary invasive procedures. The aim of the study was to compare the findings of MRCP with those of ERCP by the computation of accuracy statistics. METHODS: Thirteen electronic bibliographic databases, covering biomedical, science, health economics and grey literature were searched. A systematic review of studies comparing MRCP to diagnostic ERCP in patients with suspected biliary obstruction was conducted. Sensitivity, specificity, likelihood ratios, acceptability and adverse events were reported. RESULTS: 25 studies were identified reporting several conditions including choledocholithiasis (18 studies), malignancy (four studies), obstruction (three studies), stricture (two studies) and dilatation (five studies). Three of the 18 studies reporting choledocholithiasis were excluded from the analysis due to lack of data, or differences in study design. The sensitivity for the 15 studies of choledocholithiasis ranged from 0.50 to 1.00 while specificity ranged from 0.83 to 1.00. The positive likelihood ratio ranged: from 5.44-47.72 and the negative likelihood ratio for the 15 studies ranged from 0.00-0.51. Significant heterogeneity was found across the 15 studies so the sensitivities and specificities were summarised by a Receiver Operating Characteristic (ROC) curve. For malignancy, sensitivity ranged from 0.81 to 0.94 and specificity from 0.92 to 1.00. Positive likelihood ratios ranged from 10.12 to 43 and negative likelihood ratios ranged from 0.15 to 0.21, although these estimates were less reliable. CONCLUSION: MRCP is a comparable diagnostic investigation in comparison to ERCP for diagnosing biliary obstruction.

Journal Article↗
PubMedDate not supplied

[Strategies for endoscopic and surgical treatment of biliary tract calculi].

INTRODUCTION: Common bile duct calculi represent a pathologic entity involving obstructive icterus, cholangitis, hepatic cirrhosis or pancreatitits. Common bile duct calculi mostly have a secondary origin (from gallbladder) in 95% of cases, while primary choledocholithiasis is rare. CLASSIFICATION: From surgical aspect, common bile duct calculi can be: 1. Asymptomatic, without manifested symptoms or signs, 2. Mobile, with intermittent biliar obstruction and disobstruction, 3. Fixed, with obstruction and signs of hepato-biliary and/or bilio-pancreatic duct, 4. Transitory, microcalculi which pass through Vater's Papilla by propulsion into duodenum with symptoms. DISCUSSION: Modern biliary surgery includes diagnosis of common bile duct calculi, and if possible preoperative endoscopic (endoluminal) surgery, which is less invasive for patients. If such approach is not possible, it is necessary to perform stone extraction and cholecystectomy. CONCLUSION: Common bile duct calculi represent a common disease of the digestive system. Endoscopic diagnostic procedure is very important in management of choledocholithiasis. Endoscopic treatment of common bile duct calculi prior to cholecystectomy is a method of choice and a strategy for associated cholecysto-choledocholithiasis.

Cholelithiasis↗
PubMed1987

Value of sonography in obstructive jaundice. Limitations of bile duct caliber as an index of obstruction.

The diagnostic value of sonography was assessed in 176 patients with jaundice who had a final diagnosis on the basis of surgery, autopsy, liver biopsy, endoscopic retrograde cholangiopancreatography, and serum tests positive for hepatitis A and B. Obstructive (n = 113) versus nonobstructive jaundice (n = 63) was diagnosed with a sensitivity of 91% and a specificity of 95%. Nine of the 10 false negatives had choledocholithiasis. Application of stricter criteria for common duct (CD) dilatation than the one used of CD greater than or equal to 8 mm to greater than or equal to 12 mm would have lowered the sensitivity from 91% to 84%. On the basis of these criteria the predicted level of obstruction would have shifted from distal to proximal in 36% of the patients. Choledocholithiasis was more often associated with decreasing bilirubin values than malignancy: 55% versus 9% (p less than 0.05). The present study indicates that intermittent obstruction, usually associated with choledocholithiasis, constitutes the main problem in detection of obstructive jaundice. Diameter criteria used for diagnosing dilatation of the CD may greatly influence sonographic accuracy.

Adolescent↗
PubMed1996

Gallbladder function and recurrent stones of the biliary tract in patients after endoscopic sphincterotomy.

BACKGROUND: Change in gallbladder function may occur in patients with an intact gallbladder after endoscopic sphincterotomy (EST). This study was designed to evaluate the factors influencing gallbladder filling after EST and the correlation between gallbladder function and stone recurrence. METHODS: Sixty Chinese patients with symptomatic choledocholithiasis and an intact gallbladder received EST to clear the bile ducts. They were further investigated with sphincter of Oddi manometry (SOM), quantitative cholescintigraphy (QC), and long-term clinical follow-up. RESULTS: Fifty-six of the 60 patients in the study group were confirmed to have a loss of sphincteric function by SOM. QC showed normal gallbladder filling in 35 of these patients and delayed or non-filling in 21 patients. A significantly higher incidence of normal gallbladder filling occurred in patients with juxtapapillary diverticulum than in those without (P < 0.02), but preexisting cholecystolithiasis had no effect on it. During the follow-up period (median, 32 months: range, 9-54 months) 10 of 56 patients developed recurrent choledocholithiasis. There was no correlation between the status of gallbladder filling, preexisting cholecystolithiasis, and recurrent stones, but 9 of the 10 patients with recurrent stones had a juxtapapillary diverticulum. Repeated endoscopic treatment was satisfactory in eight patients, and only two patients received cholecystectomy. CONCLUSIONS: EST does not alter gallbladder function in most patients. Juxtapapillary diverticulum may facilitate gallbladder filling after EST, but it is also a possible factor for recurrent choledocholithiasis.

Aged↗
PubMedDate not supplied

[Acute biliary pancreatitis].

Biliary pancreatitis is a major complication of gallstones (6-8%) and mainly affects patients with microlithiasis (22%) and cholesterolosis (29%) of the gallbladder. Transient or prolonged obstruction of the ampulla represents the accepted cause and severe forms of acute pancreatitis are more frequently associated with microlithiasis (21.3% vs. 9.6%) with higher incidence of mortality (6.5% vs. 3.2%) as compared with patients with cholelithiasis. The treatment of cholelithiasis and choledocholithiasis performed electively during the same admission, after manifestations of acute pancreatitis had subsided, is an effective procedure to prevent the development of recurrent attacks of pancreatitis. Removal of the gallbladder alone in most patients may represent the definitive treatment, most common bile duct stones passing spontaneously through the papilla during the first four days after admission. Laparoscopic cholecystectomy has gained wide acceptance in the treatment of cholelithiasis, but the management of associated choledocholithiasis results still undefined. Personal strategy is to adopt a more selective approach during the acute attack, limiting the performance of ERCP-ES within the first 48 hours to those patients presenting with laboratory and clinical evidence of ampullary obstruction. If choledocholithiasis is found during laparoscopic cholecystectomy, personal recommendation is to attempt the transcystic removal of stones; if this is not feasible, a conversion of the laparoscopic procedure to an open common bile dut exploration should be carried out. Postoperative ERCP-ES does not seem a reasonably strategy, while preoperative ERCP-ES with gallbladder left in situ as treatment alone of associated biliary tract lesions may be considered in high risk patients. The surgical treatment of pancreatic lesions should be reserved to those patients with extended and unmarked or infected pancreatic necrosis, and pancreatic abscess. Closed management (surgical debridement associated with continuous local lavage of the lesser sac) is recommended, while less frequently ventral open packing should be required.

Acute Disease↗
PubMedDate not supplied

Role of operative flexible choledochoscopy in calculous biliary tract disease.

BACKGROUND: In India, no study is available regarding the use of operative choledochoscopy in the management of choledocholithiasis. ERCP facilities are not always available at many centres and usually require the expertise of a medical gastroenterologist. In contrast, operative choledochoscopy is a simpler procedure that can easily be learned and practised by many surgeons at the time of CBD exploration. AIMS: To study the role of the flexible choledochoscopy in the diagnosis and management of calculous biliary tract disorders. METHODS: Twenty four patients with choledocholithiasis underwent flexible choledochoscopy. Stones were removed either with Desjardin's forceps or by choledochoscopic instrumentation. Postoperative T-tube cholangiography was done to detect any retained stones. RESULTS: Flexible choledochoscopy was performed in a total of 24 patients. Choledochoscopy was done through a choledochotomy in 23 and through the cystic duct in one patient. The choledochoscope was used following conventional CBD exploration in 18 of the 23 patients. Complete clearance of stones was confirmed by choledochoscopy in 12 of the 18 patients and additional stones were seen in the remaining 6 patients. Fogarty balloon catheter and Dormia forceps were used to extract these stones. A CBD stricture was seen in 4 of these 18 patients and choledochoscopic biopsy was done in one of them. In 5 of the 23 patients, the choedochoscope was used as the initial exploring instrument. Impacted CBD stones were detected in 3 of the 5 patients, external compression of the CBD due to periampullary carcinoma in one and stones in both the ampulla and common hepatic duct in the last patient. Postoperative T-tube cholangiography was done in 10 patients and did not reveal any retained stones. Drainage procedures were carried out in 13 patients: 11 had choledochoduodenostomy and 2 had transduodenal sphincteroplasty. Choledochoscopy was a direct aid in choosing the operative procedure in 21 patients. CONCLUSIONS: Flexible choledochoscopy is the most effective method of CBD exploration and is essential in all patients with choledocholithiasis. No additional morbidity or mortality is caused by this procedure.

Endoscopy↗
PubMed2000

[NMR cholangiography in the diagnostic algorithm of candidates to video laparocholecystectomy].

BACKGROUND: High resolution magnetic resonance cholangiopancreatography (MRCP) is a non invasive imaging modality for depicting the pancreatobiliary tree. It can demonstrate dilation, stenosis and intraductal filling defects of both the biliary and the pancreatic duct. The imaging quality of high resolution MRCP is excellent. MRCP appears to be more effective and less invasive than endoscopic retrograde cholangiopancreatography (ERCP) to evaluate many pancreatic and biliary diseases as choledocholithiasis, malignant obstruction, incomplete or failed ERCP, postsurgical alterations of the biliary tract (as biliary-enteric anastomoses), sclerosing cholangitis, chronic pancreatitis, and congenital anomalies of the biliary and pancreatic duct. METHODS: MRCP was performed in 21 non selected patients with suspected choledocholithiasis and demonstrated the presence of stones in the biliary tract in 5 of them. In these 5 patients sequential endoscopic-laparoscopic treatment was performed and confirmed in all cases the presence of stones in the biliary tree. Laparoscopic cholecystectomy (VLC) and transcystic cholangiography was attempted in the restant 16 patients. RESULTS: Laparoscopic transcystic cholangiography confirmed in all cases the response of MRCP. CONCLUSIONS: MRCP has the potential to replace ERCP in the management of patients candidate to VLC with suspected choledocholithiasis.

Algorithms↗
PubMedDate not supplied

Approach of suspected common bile duct stones: endoscopic ultrasonography.

Recent studies have shown that endoscopic ultrasonography (EUS) is the most sensitive method for diagnosing choledocholithiasis. High sensitivities of more than 95% have been reported by several authors. Imaging the extrahepatic bile ducts and the gallbladder and searching for biliary stones are easy tasks for EUS. EUS has the advantages over ERCP to be less invasive (complication rate similar to diagnostic upper GI endoscopy) and to be able to detect small stones and sludge that can easily be masked by contrast medium during ERCP. In comparison with magnetic resonance imaging (MRI), EUS has the advantage to be close to the investigated areas and to allow the detection of very small stones or sludge, even in non dilated bile ducts. Technical limitations of biliary imaging by EUS are few: upper GI stenosis, previous gastrectomy or Billroth II resection. Imaging can be obscured by the presence of air (previous sphincterotomy or surgical bypass), surgical clips calcifying pancreatitis or a duodenal diverticulum. Main indications of EUS include the detection of choledocholithiasis in patients with a low and intermediate probability of presence of stones, in idiopathic acute pancreatitis, in mild and moderate pancreatitis after normal transabdominal ultrasonography, in pregnant women, in intensive care patients, in the diagnosis of gallbladder lithiasis or sludge, and also when MRI is contraindicated (claustrophobia and metallic implants) or fails to provide a diagnosis or is not available. Screening of choledocholithiasis with EUS has also been proposed in patients scheduled for laparoscopic cholecystectomy, but this is not common practice in Belgium.

Endosonography↗
PubMed2003

Current management of common bile duct stones in a teaching community hospital.

The advent of laparoscopic cholecystectomy (LC) has complicated management of common bile duct (CBD) stones. While LC is routine, laparoscopic CBD exploration (LCBDE) is not, and an algorithm to manage suspected choledocholithiasis has not been uniformly accepted. We evaluated current management of choledocholithiasis. Patients suspected of having CBD stones over a 2-year period were evaluated, and 42 studies in the literature were reviewed. Thirty-two patients were identified. Fourteen patients (44%) had LC with intraoperative cholangiogram (IOC) with no preoperative studies. IOC revealed CBD stones in nine (64%). Seven had CBD exploration (CBDE) at cholecystectomy, and two had postoperative endoscopic retrograde cholangiopancreatography (ERCP). CBDE was successful in five cases, and ERCP was successful in one. Eighteen patients (56%) underwent preoperative ERCP. Five (28%) had no CBD stones. ERCP removed stones in nine patients, and four had open CBDE after failed ERCP. Current literature supports LC with IOC without any preoperative studies. Laparoscopic CBDE is highly successful but depends on surgeon experience. Removing CBD stones with ERCP is also very successful but is associated with increased cost, hospital stay, and complications. We conclude that LC with IOC should be performed without preoperative ERCP when choledocholithiasis is suspected. If found, stones should be removed laparoscopically if possible.

Adult↗