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PubMed2003

Endoscopic diagnosis and treatment of post-cholecystectomy syndrome.

OBJECTIVE: To assess the value of endoscopy in the etiological diagnosis and treatment of post- cholecystectomy syndrome (PCS). METHODS: 386 patients with PCS were given endoscopic retrograde cholangiopancreatography (ERCP). Having been made the etiology clear, patients with choledocholithiasis were subjected to endoscopic sphincterotomy (EST) or endoscopic papillary balloon dilatation (EPBD) to extract stones, those with papillary inflammatory stricture to EST or EPBD, those with papillary diverticulum and sphincter of Oddi dysfunction (SOD) to EPBD, those with papillary tumor and hepatobiliary tumor to endoscopic metal biliary endoprosthese (EMBE), and those with biliary stricture in the mid bile duct, purulent cholangitis, choledocholithiasis (stones not extracted one time) and bile leakage to endoscopic nose-biliary drainage (ENBD). RESULTS: ERCP was performed successfully in 371 patients (96.1%). No abnormalities were found endoscopically in 30 patients. In 243 patients with choledocholithiasis, 235 had stones removed after one to three times. Thirty-nine patients with papillary inflammatory stricture were successfully treated with EST or EPBD. Nine patients with papillary diverticulum which oppressed the papillary opening and 7 patients with SOD were also successfully treated with EPBD. In 16 patients with stricture in the mid bile duct, 11 showed improvement after ENBD. Six patients with papillary tumor and 5 patients with hepatobiliary stricture after EMBE showed significant alleviation of jaundice. Six patients with bile leakage caused by cholecystectomy received ENBD successfully, avoiding re-operation. Six patients developed gastroduodenal ulcer and 4 residual stones in the cholecystic duct. Complications occurred in 21 patients (5.7%). CONCLUSIONS: ERCP may detect the etiology of post-cholecystectomy syndrome at early stage, and therapeutic measures can be taken accordingly in clinical practice.

Adult↗
PubMed2004

Combined laparoscopic and endoscopic treatment for bile duct diseases.

BACKGROUND: Clinical application of laparoscopy, duodenoscopy and choledochoscopy has been accepted as a mini-invasive surgical therapy for bile duct diseases; but either endoscopic or laparoscopic therapy alone is disadvantageous in its narrow indications and in failure to give full play to the individual superiority. The present study was to evaluate the procedures and therapeutic results of combined laparoscopic and endoscopic treatment for bile duct diseases. METHODS: Clinical data of 1990 patients with bile duct diseases treated by combination of laparoscopy, duodenoscopy and choledochoscopy in two hospitals were reviewed and analyzed. RESULTS: Patients with cholecystolithiasis and choledocholithiasis were treated with combined laparoscopy and duodenoscopy (n=1350) in a single operation with a cure rate of 93.6%. Those with choledocholithiasis (n=332) were treated with combined laparoscopy and choledochoscopy with a cure rate of 100%. Combined laparoscopy, duodenoscopy and choledochoscopy was used in 258 patients with choledocholithiasis (29 of them complicated with pancreatitis) and 24 patients with Mirizzi's syndrome, with a cure rate of 100%. Laparoscopic choledochoenterostomy and preoperative endoscopic nasobiliary drainage were done in 26 patients with a cure rate of 100%. There were no serious operative complications. A follow-up study of 1051 patients for 3 months to 12 years (mean 7.8 years) showed that 10 patients had recurrence of stones but no stenosis of the bile duct. CONCLUSION: Combined laparoscopic and endoscopic procedures are mini-invasive and cause less pain and minimal operative complications.

Adolescent↗
PubMed1990

Endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy--a Singapore experience.

We performed endoscopic retrograde cholangiopancreatogram (ERCP) on 200 patients over a four and a half year period. The duct of interest was successfully cannulated in 173 cases (87%). The most common indications were obstructive jaundice, cholangitis, chronic upper abdominal pain and suspected pancreatic disease. The commonest findings were cholelithiasis and malignant strictures of the common bile duct (CBD). Forty seven patients (27%) had normal examinations. Sixty-two of 87 (71%) patients with choledocholithiasis underwent endoscopic sphincterotomy (ES). The success rate for active stone extraction was 82% (27/33) while 64% (14/22) of patients managed expectantly cleared their CBD stones spontaneously after ES. The immediate complication rate of ES was 13% and included pancreatitis, stone impaction, cholangitis and bleeding. There was no complications amongst patients who underwent ERCP alone and no mortality in this series. Twenty three patients (26%) with choledocholithiasis proceeded to surgery because the stones were considered too large to remove endoscopically. One patient had endoscopic stone removal without prior ES while another had a permanent stent inserted for drainage. We conclude that ERCP and ES are useful and safe modalities in the assessment of biliary tract diseases and the treatment of choledocholithiasis.

Adult↗
PubMed1989

[Intraoperative cholangiography: its value in simple cholelithiasis].

The present study evaluates the benefits of systematic intraoperative cholangiography (CIO) in 144 patients without preoperative suspicion of choledocholithiasis. Eleven (7.6%) of the intraoperative cholangiographies were considered abnormal by the surgeon and the presence of choledocholithiasis (3/11, 27%) was confirmed in only three cases. Pathology of the main bile duct that had been unsuspected preoperatively was found in only 2% (3/144). We conclude that routine intraoperative cholangiography of patients without preoperative suspicion of choledocholithiasis increases the cost of surgery, prolongs operative time, exposes the patient to radiation and sometimes yields false positives (5%) that lead to unnecessary exploration of the choledochus, which is accompanied by a potential increase in morbidity and a real prolongation of the postoperative hospital stay.

Cholangiography↗
PubMed1989

Histological analysis of liver parenchyma and choledochal wall, and external diameter and intraluminal pressure of the common bile duct in controls and patients with common bile duct stones with and without acute suppurative cholangitis.

The purpose of this prospective controlled study was to determine the changes in intraluminal pressure and diameter of the common bile duct in a total of 121 bile patients with choledocholithiasis, and the consequences of these alterations for choledochal mucosa and liver histology. In fact, the reflux of bacteria from the obstructed biliary tract into the bloodstream is responsible for producing the clinical syndrome of acute suppurative cholangitis. Group I (26 patients) served as controls, Group II (50) had choledocholithiasis with clear green bile, and Group III (45) were patients with acute suppurative cholangitis with pus in the biliary tract. Ultrasonography revealed gallstones in all the patients. The external diameter of the common bile duct in patients with choledocholithiasis and acute suppurative cholangitis was significantly greater than in those of the other groups. Patients with acute suppurative cholangitis also had a higher intraluminal pressure than those of Groups I or II.

Acute Disease↗
PubMed1989

[Liver lipids in patients with cholelithiasis].

The different hepatic lipid fractions of patients suffering choledocholithiasis of cholesterol stones exclusively, have been studied by thin layer chromatography. None of the patients studied had metabolic disorders, were alcohol abusers or obese, or were on any treatment that could alter lipid metabolism. The liver concentration of cholesterol and triglycerides in these patients was greater than in control subjects without choledocholithiasis. The liver concentration of esterified cholesterol and triglycerides was greater in female patients with choledocholithiasis than in males, while some other phospholipid fractions were lower.

Adult↗
PubMedDate not supplied

[Sphincteroplasty: its value in the treatment of distal lithiasis of the choledochus].

Twenty patients in whom sphincteroplasty was performed are presented. In 12 cases the indication was choledocholithiasis with stone impacted in the distal bile duct; 5 cases with choledocholithiasis and oddian stenosis, and 3 cases with residual choledocholithiasis associated with oddian stenosis. The average length of the incision of the ampullary area was 25 mm. The postoperative control made by tube cholangiography evidenced the presence of a wide open choledochoduodenal opening. Amylase activity was followed in all patients. One case of acute pancreatitis and one case of choledochal fistula were recorded as postoperative complications.

Adult↗
PubMed1988

[Lithiasis of the common bile duct in the aged subject treated with endoscopy (227 patients)].

One hundred and sixteen patients aged from 65 to 80 years (first group including 39 previously cholecystectomized patients) and 161 patients aged over 80 years (second group, including 31 previously cholecystectomized patients) underwent endoscopic papillotomy for choledocholithiasis. We compared clinical, biochemical and morphological features of choledocolithiasis with early results of endoscopic papillotomy. Clinical symptoms were not different between the old and very old patients, cholecystectomized or not. Charcot's triade was observed in one third of patients. Biochemical data just before endoscopic retrograde cholangiography were not different according to groups: 21 p. 100 of the 277 patients had a biological cholestasis without elevation of bilirubin and 10 p. 100 of the patients had no abnormality of the liver function. Diagnosis of choledocholithiasis was accurately suspected in 90 p. 100 of patients. Complete removal of gallstones after endoscopic papillotomy was obtained in 95 p. 100 of patients in the first group and 93 p. 100 of patients in the second group. Morbidity and mortality rates related to endoscopic papillotomy were not different between the 2 groups (6.9 and 0.8 p. 100 in the first group and 8.7 and 3.1 p. 100 in the second group, the first group and 8.7 and 3.1 p. 100 in the second group, respectively). These results suggest that clinical and biochemical features of choledocholithiasis, and early results of endoscopic treatment do not present any particularities in the elderly.

Aged↗
PubMed1988

Endoscopic retrograde sphincterotomy in the treatment of biliary tract disease.

Endoscopic retrograde sphincterotomy (E.R.S.) is rapidly becoming popular. In the past 5 years, E.R.S. was technically successful in 124 of 130 patients (95%) in whom it was attempted. One hundred twenty four had choledocholithiasis, and six had papillary stenosis after cholecystectomy. Urgent E.R.S. was performed for septic cholangitis in 12 patients and biliary pancreatitis in four. There were six patients with choledocholithiasis in whom sphincterotomy was not possible. Of the 118 patients with successful papillotomy for choledocholithiasis, spontaneous passage of calculi after E.R.S. occurred in 28 cases (24%), and instrumental extraction of stones was possible in 81 (69%). Duct clearance failed in nine patients (8%), mostly due to the large size of the retained stones. The largest stone extracted was 26 mm in diameter. The overall success rate of removing common bile duct stones was 109 in 118 cases (88%). In patients with papillary stenosis, E.R.S. was successful in relieving symptoms and biochemical cholestasis in six of six cases (100%). Complications occurred in only two patients. The complications were pancreatitis in one and hemorrhage in one. None of these patients required surgical treatment of the complication. Endoscopic retrograde sphincterotomy is effective for the removal of stones of the common bile duct, and at relieving the symptoms of papillary stenosis. It is safe in experienced hands and has led to only rare complications.

Adult↗
PubMed1985

Prediction of operative cholangiography in patients undergoing elective cholecystectomy with routine liver function chemistries.

A retrospective reviews of 195 consecutive patients who underwent elective cholecystectomy and operative cystic duct cholangiography (OCDC) were reviewed to establish criteria to correlate the preoperative laboratory data of liver chemistry tests and the actual biliary tract disease found in each patients. Patients who had a history of jaundice or other clinical indication for common bile duct exploration were excluded from this study. The patients were divided into four groups based on the results of the OCDC: I negative, II false positive, III false negative, and IV positive for choledocholithiasis. The results of the preoperative liver chemistry studies of the patients in each of the four groups were analyzed by the chi 2 method. The four liver chemistry tests were lactate dehydrogenase, SGOT, bilirubin, and alkaline phosphatase. When results of all preoperative liver chemistry tests were normal, there was no incidence of choledocholithiasis. As the number of chemistry test result elevations increased from one to four, the incidence of choledocholithiasis increased from 17% to 50% (p less than 0.001). Preoperative liver chemistry tests in selected patients undergoing elective cholecystectomy may provide a valuable indicator to the surgeon as to whether an OCDC should be performed at the time of surgery.

Alkaline Phosphatase↗
PubMed1984

Biliary tract disease in Thailand.

One hundred and eighty-nine patients were documented as having biliary tract disease. Two hundred and nine lesions were found. The prevalence of malignant disease of the biliary tract was represented by 30.1 per cent, and cholangiocarcinoma was a leading cause. The carcinogenesis of cholangiocarcinoma has been speculated. Acute cholecystitis represented 55 per cent of biliary tract disease in Thailand, which consisted of acute calculous cholecystitis and acute noncalculous cholecystitis, 94.8 and 5.2 per cent, respectively. Among acute calculous cholecystitis, the prevalence of cholelithiasis, choledocholithiasis and intrahepatic stones were 58.5, 68.8 and 15.6 per cent, respectively. The high prevalence of choledocholithiasis and intrahepatic stones requires elucidation. In the remaining surgical disease of the biliary tract, opisthorchiatic cyst was the most common cause. The diagnosis of opisthorchiatic cyst was made roentgenologically in association with the identification of Opisthorchis ova in the aspirated bile. Opisthorchiatic cyst appears to be a unique clinical entity, differing from other types of intrahepatic cysts. Another form of presentation of biliary tract opisthorchiasis is through obstruction of the common bile duct by an aggregated mass of dead worms. This condition is cured by surgical removal of the worms. It is worth while to mention that, among 189 patients with biliary tract disease, there were three documented instances of choledochal cysts. This probably indicates a high prevalence of choledochal cysts when compared with that for the United States. In the present study, a 36 year old female with a diagnosis of Caroli's disease, ascariasis of the common bile duct and choledocholithiasis is presented.

Acute Disease↗
PubMed1981

Common bile duct exploration: indications and results.

To ascertain the best diagnostic indicators of choledocholithiasis and to decrease the incidence of retained stones in the common bile duct after exploration, the authors carried out a retrospective review of 110 consecutive patients who underwent common bile duct exploration for calculous biliary tract disease. Conditions that were most often associated with choledocholithiasis were cholangitis and clinically obvious jaundice. The serum bilirubin level was helpful in identifying patients with stones in the common bile duct only when the value was greater than 6 mg/dl (103 mumol/l), and alkaline phosphatase only when the value was more than 250 IU (normal 110 IU). When stones are felt in the duct at operation, the diagnosis of choledocholithiasis is certain; positive operative cholangiograms are highly reliable and the coexistence of small gallstones and a dilated cystic duct is suggestive. The retention of stones is best prevented by careful exploration followed by high-quality T-tube cholangiography performed at operation after the exploration is complete. Any missed stones found in this way should be removed by re-exploration at the time of the original operation. Stones left in the common bile duct are best extracted nonoperatively under radiologic control. This technique, while effective and safe, is associated with considerable morbidity.

Cholangiography↗
PubMed1995

Biliary tract calculi in primary sclerosing cholangitis.

UNLABELLED: By conventional criteria the diagnosis of primary sclerosing cholangitis (PSC) is excluded if biliary tract calculi are present. OBJECTIVE: To compare patients with sclerosing cholangitis with and without calculi. METHODS: Retrospective review between 8/91 and 9/93 identified 63 patients with sclerosing cholangitis alone (Group A) and 22 patients with sclerosing cholangitis and biliary tract calculi (Group B). The mean follow-up was 13.6 months. Clinical features reviewed were age, sex, associated inflammatory disease (IBD), and clinical presentation. Cholangiographic features compared were site and extent of disease. Endoscopic stone extraction was reviewed for success and complications. RESULTS: Both groups had the following features in common: 1) mean age (45.9 vs 46.3 yr), 2) prevalence of IBD (68.3 vs 72.7%), 3) extent of bile duct strictures (intrahepatic: 28.5% vs 27.2%; extrahepatic: 12.7% vs 13.6%; both: 58.7% vs 54.5%). There were proportionately more women in Group B (45.5% vs 33.3%). Symptomatic presentation (pain, pruritus, jaundice, and cholangitis) was seen more often in Group B: 86.4% compared with Group A: 39.7% (specifically cholangitis was seen in 22.7% vs 4.7%). Among Group B, calculi developed subsequent (mean 40.2 months) after the diagnosis of sclerosing cholangitis in 77.3% of patients. The distribution of calculi was cholelithiasis: 7 (31.8%); choledocholithiasis: 9 (40.9%); and both: 6 (27.2%). Of the patients with choledocholithiasis alone, 78% had undergone previous cholecystectomy. Endoscopic stone extraction was successful in 13 (86.6%) of the patients with choledocholithiasis. Complications included mild pancreatitis in one patient and bleeding from sphincterotomy site in another patient which responded to sclerotherapy. In follow-up, only one patient had recurrent calculi and underwent successful stone extraction. CONCLUSION: We suggest that biliary tract calculi are a part of the spectrum of otherwise typical PSC and therefore their presence should not necessarily exclude the diagnosis.

Adult↗
PubMed1994

[Recurrent lithiasis of the efferent bile ducts in patients with a diverticulum in Vater's papilla].

The problem of residual choledocholithiasis is a subject discussed for decades by surgeons and gastroenterologists. In particular at present when patients with cholecystolithiasis are operated mainly by the laparoscopic route, this questions is again a frequently discussed topic. The submitted paper evaluates the incidence of choledocholithiasis in a group of 403 patients. From the investigation ensues among others that the presence of diverticula in the area of the ampulla of Vater is associated with a higher incidence of choledocholithiasis.

Adult↗
PubMedDate not supplied

[Imaging technics in the indications for laparoscopic cholecystectomy. Echotomography and cholangiography compared].

March 1991 through October 1992, in the Clinica Chirurgica II of the Bologna University, 59 patients were submitted to laparoscopic cholecystectomy; the age range was 25 to 76 years and the mean 50 years. In no patient stones bigger than 35 mm were observed and 31% of the subjects were treated with litholysis before surgery. Fifty-eight patients were affected with single or multiple cholelithiasis, 1 had adenomyomatosis and 4 patients had associated choledocholithiasis treated with preoperative ERCP. Both US and cholangiography were performed to detect absolute contraindications--e.g., acute cholecystitis, cholangitis, peritonitis and cirrhosis--or relative contraindications--e.g., choledocholithiasis, > 5 mm stones and short cystic duct. US proved to be more sensitive than cholangiography to assess the number of stones and gallbladder wall thickness and to diagnose acute cholecystitis or scleroatrophic gallbladder, but it appeared to be less reliable in case of choledocholithiasis, where cholangiography was the technique of choice, and in possible anatomical variations--e.g., short cystic duct--which must be detected before laparoscopic cholecystectomy. Cholangiography appeared to be rather inadequate to study cholelithiasis when associated with functional gallbladder exclusion (as it happened in 17% of our patients). Intraoperative cholangiography was performed on 2 patients only, because their obesity hindered the preoperative study. In conclusion, the need is stressed of combining US and cholangiography for the accurate preoperative evaluation of gallbladder stones patients.

Adult↗
PubMed1995

Selected versus routine use of intraoperative cholangiography during laparoscopic cholecystectomy.

Routine use of intraoperative cholangiography during laparoscopic cholecystectomy is still widely advocated and standard in many departments, however, this is discussed controversially. We have developed a new diagnostic strategy to detect bile duct stones. The concept is based on an ultrasound examination and on a screening for the presence of six risk indicators of choledocholithiasis. 120 consecutive patients undergoing laparoscopic cholecystectomy were prospectively screened for the presence of six risk indicators of choledocholithiasis: history of jaundice; history of pancreatitis; hyperbilirubinemia; hyperamylasemia; dilated bile duct; unclear ultrasound findings. The sensitivity of ultrasound and of intraoperative cholangiography in diagnosing bile duct stones was also evaluated. For the detection of bile duct stones, the sensitivity was 77% for ultrasound and 100% for intraoperative cholangiography. 20% of all patients had at least one risk indicator. The presence of a risk indicator correlated significantly with the presence of choledocholithiasis (p < 0.01, chi-square-test). The negative predictive value of the total set of risk indicators was 100%. Following our diagnostic concept, we would have avoided 80% of intraoperative cholangiographies without missing a stone in the bile duct. This study lends further support to the view that the routine use of intraoperative cholangiography in patients undergoing laparoscopic cholecystectomy is not necessary.

Adult↗
PubMed1996

Selective endoscopic retrograde cholangiography and preoperative bile duct stone removal in patients scheduled for laparoscopic cholecystectomy: a prospective study.

OBJECTIVES: Laparoscopic cholecystectomy (LC) has become the treatment of choice for patients with symptomatic cholelithiasis. About 10% of patients with symptomatic gallstones may bear associated common bile duct (CBD) stones. The preferred approach to these patients is the removal of CBD stones by endoscopic retrograde cholangiography (ERCP) before LC. However, ERCP before LC should be performed only in patients with suspected choledocholithiasis. The aims of this study were to: 1) generate an efficacious predictive model for selecting patients with suspected choledocholithiasis to submit to preoperative ERCP, and 2) test the safety of the endoscopic/laparoscopic procedure. METHODS: Historical, biochemical, and ultrasonographic data were collected prospectively. Receiver operating characteristics curve analysis was adopted for determining optimal biochemical and ultrasonographic cut-off values. Multivariate analysis using logistic regression with generation of the best model identifying independent predictors of CBD stones was also employed. RESULTS: The optimal model predicted a 95% probability of CBD stones in a patient who presented with elevated ALP (over 300 IU/L) and ALT (over 40 IU/L) levels and CBD dilation > 8 mm at ultrasonography. Endoscopic removal of CBD stones was achieved in 95% of patients, with minimal morbidity and no mortality. CONCLUSIONS: The identified independent predictors of CBD stones are highly efficient selectors of patients with choledocholithiasis. Moreover, endoscopic removal of CBD stones before LC is a safe and efficacious procedure.

Adolescent↗
PubMed1996

The current management of common bile duct stones.

Choledocholithiasis is usually proven by cholangiogram during cholecystectomy, and today nearly all cholecystectomies are performed laparoscopically. Patients expect to be discharged from the hospital within 24 hours after laparoscopic surgery and return to work in 1 week. Surgeons must develop advanced laparoscopic skills to allow choledocholithiasis to be managed laparoscopically with one procedure and one anesthetic. Interventional radiologists and gastroenterologists can frequently detect and manage common duct stones that cause severe cholangitis and pancreatitis and that occur in patients too debilitated for general anesthesia. In the majority of patients, common duct stones demonstrated at laparoscopic cholecystectomy may be removed using laparoscopic transcystic techniques. Whether complicated CBD stones are optimally managed by laparoscopic choledochotomy, conversion to open common duct exploration, or left for postoperative ERC/ES is controversial and depends on the expertise of the surgeon, gastroenterologist, and wishes of the patient. Although the authors propose one algorithm for the current management of CBD stones, the superiority of the laparoscopic treatment for CBD stones is not yet proven. Multi-institutional, randomized trials comparing laparoscopic, endoscopic, and combined techniques for ductal clearance will be necessary to establish the optimal therapy of choledocholithiasis in the 1990s.

Cholangiography↗