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PubMed1994

Laparoscopic ultrasonography in the evaluation of the biliary tree during laparoscopic cholecystectomy.

A prospective comparative study to evaluate operative cholangiography and laparoscopic ultrasonography in the detection of common bile duct (CBD) stones was undertaken in 54 patients undergoing laparoscopic cholecystectomy. Laparoscopic ultrasonography with a 7.5-MHz linear-array probe was performed before gallbladder mobilization. The incidence of choledocholithiasis at operation was 13 percent (seven patients). Cholangiograms were not obtained in six patients, one of whom had common duct stones identified by laparoscopic ultrasonography. Operative cholangiography detected five of the remaining six CBD stones with two false-positive examinations. Laparoscopic ultrasonography detected five of the seven stones with two false-positive examinations. The finding of a CBD diameter of 7 mm or greater and gallbladder stones of up to 3 mm in diameter by laparoscopic ultrasonography would have identified all patients with common duct stones and implies that none of these would have undergone false duct exploration. Laparoscopic ultrasonography is useful in the detection of choledocholithiasis.

Adult↗
PubMed1995

[Selective intraoperative cholangiography in laparoscopic cholecystectomy].

Routine use of intraoperative cholangiography during laparoscopic cholecystectomy is still widely advocated and standard in many departments; however, it is controversial. We have developed a new diagnostic strategy for the detection of bile duct stones. The concept is based on an ultrasound examination and on screening for the presence of six risk indicators of choledocholithiasis. A total of 120 patients undergoing laparoscopic cholecystectomy were prospectively screened for the presence of these six risk indicators: history of jaundice, history of pancreatitis, hyperbilirubinemia, hyperamylasemia, dilated bile duct, and unclear ultrasound findings. The sensitivity of ultrasound and 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. Twenty percent 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 routine use of intraoperative cholangiography is not necessary.

Adult↗
PubMed1996

Intraoperative ultrasonography (IOUS) during laparoscopic cholecystectomy.

BACKGROUND: The purpose of this study was to evaluate the usefulness of intraoperative ultrasonography (IOUS), a new method of imaging the biliary tree and related structures, during laparoscopic cholecystectomy. METHOD: An IOUS probe (Aloka, Tokyo, Japan) with a 7.5-MHz linear-array transducer was used during cholecystectomy in 124 patients with symptomatic cholelithiasis (45 men, 79 women; mean age, 48 +/- 14 years). RESULTS: The examination of the common bile duct (CBD) was excellent in 117 patients but unsatisfactory in 7 cases (5.6%) at the level of the head of the pancreas. In 5 patients, IOUS showed unsuspected choledocholithiasis: a subsequent intraoperational cholangiogram confirmed this. In five cases IOUS was able to help the surgeon to localize a Calot area obscured by inflammation. Postoperatively, one patient had an injury of the cystic duct stump: a nasobiliary tube resolved the bile leakage after 7 days. Another patient was submitted to postoperative endoscopic retrograde cholangiopancreatography (ERCP) for a choledocholithiasis recognized by a trans-cystic-tube cholangiography: the stone was suspected but not demonstrated either by laparoscopic IOUS or by intraoperative cholangiography. During the follow-up period, one patient had an episode of acute pancreatitis. ERCP showed a small stone wedged in the sphincter of Oddi. CONCLUSIONS: IOUS may be a real alternative to cholangiography during laparoscopic cholecystectomy since it is safer and offers a complete examination of the biliary tree. It has some disadvantages which can solved by additional experience.

Adult↗
PubMed1988

Is ERCP manometry useful in the choice of treatment of stones of the common bile duct?

To verify the appropriateness of sphincterotomy as the treatment of choice of choledocholithiasis, since 1980 we have been using endoscopic retrograde cholangiopancreatographic (ERCP) manometry of the sphincter of Oddi (SO). This method allows direct investigation of SO motor activity and provides useful information regarding the presence of benign papillary stenosis (BPS). Thirty-four patients were investigated because the radiological examination indicated BPS might be present. Of these, 20 had common bile duct (CBD) stones, while the remaining 14 presented with biliarylike pain and one or more of the following: CBD dilation (larger than 12 mm); emptying of the ERCP contrast medium took longer than 45 min; abnormal liver function tests. Moreover, 8 healthy volunteers served as controls. Our results show that the incidence of SO motor anomalies is very low in the presence of choledocholithiasis, while it is substantial in patients with suspected SO dysfunction. These observations would suggest that, unlike the traditional view, BPS is rarely secondary to biliary lithiasis. Therefore, most of the sphincterotomies performed that are based on the assumption of underlying SO pathology should be considered unnecessary. Under these circumstances, the physiological role of a functioning SO has induced us to advocate sphincterotomy, surgical or endoscopic, in selected cases only.

Adult↗
PubMed1993

Surgery for cholelithiasis in cirrhotic patients.

Although biliary tract surgery for cholelithiasis is performed frequently in Japan, cirrhotic patients require special consideration. Postoperative complications after biliary tract surgery were studied in 23 patients with liver cirrhosis and associated cholelithiasis, 9 of whom had no complications, 8 had minor complications, and 6 had severe complications. Concerning the relation between Child's classification and postoperative complications, no complications were seen in four Child's type A patients, but seven of ten (70%) Child's type B patients and seven of nine (78%) Child's type C patients developed complications. Two (20%) of the Child's type B patients and four (44%) of the Child's type C were severe, and three of the latter group died. Regarding the preoperative laboratory findings, significant differences were seen between the patients without complications and those with severe complications in serum bilirubin, albumin, and ICG R15 values. Of the six patients with severe complications, five had choledocholithiasis, three of whom died of liver failure, while two developed biliary peritonitis caused by insufficient fistula formation after removal of the T-tube. Thus, for the treatment of choledocholithiasis in patients with severe cirrhosis, avoiding surgical invasion through the use of such techniques as endoscopic papillotomy is recommended whenever possible.

Biliary Tract Surgical Procedures↗
PubMedDate not supplied

Role of extracorporeal shock wave lithotripsy in hepato-biliary-pancreatic surgery.

Since the early 1980s extracorporeal shock wave lithotripsy (ESWL) has partially replaced major operative procedures in various fields of surgery. In the interest of the patient, it is important to determine the exact role of ESWL in surgery. Comparing our own prospectively followed patients with other patient series, we have tried to assess this role. We treated 133 patients with cholecystolithiasis, 80 patients with choledocholithiasis, and 17 patients with pancreatic stones using a second-generation lithotriptor, the Siemens Lithostar (Siemens, Erlangen, Germany). The results suggest a limited role of ESWL for cholecystolithiasis, in which it is reserved for patients with high operative risk and patients who reject an operation. For choledocholithiasis ESWL seems to become an integral part of the treatment in the elderly patient in whom endoscopic stone removal proved impossible. Finally, ESWL could become a first option for the treatment of intractable pain in patients with chronic calcifying pancreatitis.

Adult↗
PubMed1998

Infected bile-induced acute pancreatitis in rabbits. The role of bacteria.

CONCLUSIONS: Bacteria species commonly found in bile of patients with choledocholithiasis render human bile toxic to the pancreas. The severity of infected bile-induced acute pancreatitis depends on the bacterial species. Infected bile-induced acute pancreatitis turns into a sterile inflammation within 10 d. BACKGROUND: Flow of bile into the pancreatic duct was proposed to cause some forms of gallstone pancreatitis. The development of bile-induced acute pancreatitis at physiologic ductal pressure is known to depend on the bacterial infection of bile. In this study, we investigated the effect of a variety of bacteria species commonly found in bile of patients with choledocholithiasis upon the pancreatic toxicity of human bile. The time-course of pancreatic infection in infected bile-induced acute pancreatitis was also analyzed. METHODS: In rabbits, the pancreatic duct was kept obstructed throughout the experiment. After 24 h, 50 microL of pancreatic juice was obtained from the congested pancreatic duct and replaced with the same quantity of infected human bile. Bile contained bacteria (10(7) microorganisms/microL) of species frequently found in choledochal secretions of patients with gallstone disease. Effects on pancreatic morphology were studied after 48 h. In another experiment, the number of Escherichia coli/mg of pancreatic tissue was determined in a time sequence study following exposure of the rabbit pancreatic duct to 50 microL E. coli-infected bile (10(7) microorganisms/mL) and temporary (12 h) or permanent duct obstruction. RESULTS: Sterile bile was not harmful to the pancreas. Infected bile caused an interstitial-edematous pancreatitis with occasional acinar necrosis. The severity of acute pancreatitis depended on the bacterial species. Following pancreatic duct exposure to E. coli-infected bile, there was complete clearance of the bacteria from the gland with a concomitant interstitial leukocyte infiltration within a period of 2-10 d.

Acute Disease↗
PubMed1992

Laparoscopic common bile duct exploration.

Laparoscopic cholecystectomy is now the standard approach to gallbladder disease. While laparoscopic cholecystectomy offers many advantages over the conventional laparotomy procedure one of its drawbacks is that a synchronous common bile duct exploration, for so long a cornerstone of management of choledocholithiasis, is not yet widely practised laparoscopically. Endoscopic sphincterotomy or open surgery, with their attendant hazards and morbidity, remain the most common approaches. A flexible choledochoscope with an operating channel may in future facilitate laparoscopic management of choledocholithiasis but as yet this is not widely available. We report the removal of a common duct stone by dormia basket extraction through the cystic duct at laparoscopic cholecystectomy.

Aged↗
PubMed1996

[Double balloon catheter for facilitating (laparoscopic) choledochus drainage].

In laparoscopic management of choledocholithiasis the drains available for bile-duct drainage are problematic. Since November 1991 we have given priority to the laparoscopic management of common bile-duct stones (n = 97). In cooperation with industry (W. Rüsch/D-Waiblingen), we have developed a double-balloon catheter for laparoscopic application. In 15 cases we used this double-balloon catheter. There were no complications like dislocation, obstruction or leakage. This new catheter facilitates the procedure of laparoscopic bile-duct exploration in choledocholithiasis. The operating time is reduced and removal of residual concrements is easily possible.

Catheterization↗
PubMed2003

Retained common-duct stones after open cholecystectomy and duct exploration in children.

A retrospective study was performed of 250 patients with cholelithiasis treated at the Royal Children's Hospital, (RCH) Melbourne, over 25 years by open operation; 32 (12.8%) had proven choledocholithiasis on either preoperative imaging, operative cholangiography (OpCG), or postoperative investigation. A further 3 had underlying congenital biliary abnormalities and were excluded from further study. Thirty-one of the 32 were explored at open operation, 27 after OpCG and 4 on clinical grounds. One retained common-bile-duct (CBD) stone was undetected until the postoperative period (1/250, 0.25%). Seven ducts were not cleared, giving a duct exploration failure rate of 22.6% (7/31). All 8 retained CBD stones were identified in the early postoperative period and managed with a variety of techniques, including endoscopic retrograde cholangio-pancreatography (ERCP). The incidence of retained stones after open CBD exploration was high (22.6%), and can be attributed to difficulties in operative technique dealing with the smaller paediatric CBD. In addition, haemolytic disease seems to induce a propensity for choledocholithiasis. Given the small numbers presenting with cholelithiasis to RCH (10 per year), it is suggested that a selective approach to CBD exploration is appropriate in children. With the increasing use of laparoscopic cholecystectomy in children and the inherent technical difficulties of laparoscopic operative cholangiography, ERCP may offer an alternative solution in dealing with CBD stones rather than open or laparoscopic CBD exploration.

Adolescent↗
PubMed2004

The standard of laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy today is the standard operation for all gall stone disease. Nevertheless, a number of questions are still being discussed: What are the optimal steps? Or, more important, is the laparoscopic technique really superior to the open procedure according to the criteria of evidence-based medicine? How should we proceed in case of an occult choledocholithiasis? Is intraoperative cholangiography mandatory, and does the concept for the treatment of silent gall stones need to be revised in the era of laparoscopic cholecystectomy? METHOD: Literature review. RESULTS: Eleven randomised studies show the superiority of the laparoscopic technique. Only one study shows no advantage provided the length of the incision in the open procedure is less than 8 cm. According to our own experience, up to 98% of all gall bladders can be removed laparoscopically when following the described standard technique, with a conversion rate of less than 1%. In the case of an occult choledocholithiasis the concept of "therapeutic splitting" has proved successful; the risk of a residual stone is below 1%. Routine intraoperative cholangiography is not cost effective. The risk of complications for a silent gall stone in the long term is higher than for laparoscopic cholecystectomy in young patients with incidental gall stones. CONCLUSION: The laparoscopic technique has given new impulses to the surgery of the gall bladder and has proven to be an effective, patient-friendly alternative to open surgery.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed2003

Management of cholangitis.

Acute cholangitis remains a life-threatening complication of biliary obstruction, particularly in the elderly with comorbid disease or when there is a delay in diagnosis and treatment. The initial management consists of fluid resuscitation, correction of coagulopathy, and administration of broad-spectrum antibiotics. The choice of antibiotics should cover both gram-negative and gram-positive organisms associated with cholangitis until the results of a blood culture are available. The timing and choice of biliary decompression varies depending on the response to antibiotic therapy, the presence of comorbid disease, and the underlying cause. Biliary sepsis resolves in most patients with conservative treatment, thus allowing time to perform more detailed non-interventional imaging (e.g., spiral computed tomography [CT], magnetic resonance cholangiopancreatography [MRCP]) to determine the underlying cause and level of biliary obstruction. Those with cholangitis who do not respond to conservative therapy will require urgent biliary decompression. In patients with choledocholithiasis, endoscopic drainage is now the treatment of choice or, if this fails, transhepatic biliary decompression is a useful alternative. Various endoscopic options are available for managing choledocholithiasis, ranging from endoscopic papillotomy (EP) and extraction of stones, to the placement of a biliary drainage system. In patients who respond to antibiotic therapy, EP with stone extraction is preferred, while in those with ongoing sepsis and multiple large stones, the placement of a stent with or without an EP is the safest option. Transhepatic biliary drainage is now reserved for failure of endoscopic drainage and for patients with suspected hilar cholangiocarcinoma or intrahepatic stones. Surgical biliary decompression is seldom required in the emergency setting, but still plays an important role in the definitive treatment of the underlying cause.

Anti-Bacterial Agents↗
PubMed2006

Timing of laparoscopic cholecystectomy for subacute calculous cholecystitis: early or interval--a prospective study.

BACKGROUND/PURPOSE: The aim of this prospective study was to evaluate the safety and feasibility of early laparoscopic cholecystectomy for subacute cholecystitis and to compare it with interval laparoscopic cholecystectomy. METHODS: The study was performed in 74 patients who had been diagnosed with subacute cholecystitis between January 2000 and June 2005. The patients were divided into two groups. The early laparoscopic cholecystectomy group was composed of 31 patients who underwent laparoscopic cholecystectomy 24 h after admission to the hospital. The interval laparoscopic cholecystectomy group was composed of 43 patients who underwent laparoscopic cholecystectomy 8-12 weeks after medical treatment. RESULTS: There was no significant difference between the conversion rate, intraoperative bleeding, need for intraoperative cholangiography, minor bile duct injury, and postoperative complications in the two groups. Eleven patients in the interval group underwent urgent laparoscopic cholecystectomy or additional procedures because of recurrent cholecystitis, choledocholithiasis, or biliary pancreatitis. The early group had a significantly shorter total hospital stay (P = 0.031), lower cost of treatment (P = 0.042), and less difficulty with Calot's triangle dissection (P = 0.008). CONCLUSIONS: Early laparoscopic cholecystectomy can be done without hesitation in patients with subacute cholecystitis, in the light of obstacles observed in the interval group, such as dissection difficulty, lack of success in "cooling down", and additional problems such as choledocholithiasis and biliary pancreatitis.

Adult↗
PubMed2002

Development of a bent-type tube stent for simultaneous drainage of bile and pancreatic juice.

BACKGROUND/PURPOSE: Endoscopic lithotomy is a useful medical procedure for treating choledocholithiasis. Although this procedure is commonly performed, complications such as pancreatitis and cholangitis are recognized as major and serious problems. The obstruction of bile and pancreatic juice flow caused by papillary edema or spasm is thought to be responsible for such complications. We have developed a new bent-type tube stent that can drain bile and pancreatic juice simultaneously. METHODS: From June to November 2001, temporary implantation of the new bent-type tube stent was performed in four patients (two women, two men; mean age, 73.3 years) with choledocholithiasis, for the drainage of bile and pancreatic juice simultaneously after endoscopic lithotomy by endoscopic sphincterotomy or endoscopic balloon sphincter dilatation. RESULTS: Immediately after the implantation of the new type of tube stent, bile and pancreatic juice flow from the respective ducts was recognized under endoscopic observation. Neither pancreatitis nor cholangitis occurred after these procedures. CONCLUSIONS: This procedure may be a helpful means to prevent pancreatitis and cholangitis after endoscopic lithotomy.

Aged↗
PubMed2007

EUS yield in evaluating biliary dilatation in patients with normal serum liver enzymes.

The finding of common bile duct (CBD) dilatation on abdominal imaging frequently results in additional testing. It has been our impression that endoscopic ultrasound (EUS) evaluation of a dilated CBD is a low-yield examination in the setting of normal serum liver enzymes. We therefore sought to evaluate the EUS yield in evaluating CBD dilatation in patients with normal as compared to elevated serum liver enzymes. A retrospective review was performed to identify patients referred for EUS evaluation of a dilated CBD in the absence of obvious pathology on prior imaging. Charts were reviewed for patient symptoms, presence of elevated serum liver enzymes, imaging studies before EUS, and EUS findings. Exclusion criteria included clinical jaundice, known biliary stricture, mass lesion or stone, and previously sphincterotomy and/or stent placement. Forty-seven patients were identified: 32 with normal and 15 with elevated serum liver enzymes. There was no difference in mean CBD diameter between these two groups (8.51 vs. 8.79 mm, p=0.854). Of the entire group, 15 patients had undergone prior magnetic resonance cholangiopancreatography (MRCP); an additional 7 patients had undergone prior endoscopic retrograde cholangiopancreatography (ERCP). EUS findings to explain CBD dilatation were found more commonly in patients with elevated compared with normal serum liver enzymes (53% vs. 6%, p=0.001). Periampullary diverticula and choledocholithiasis were the most common findings; of 32 patients with normal serum liver enzymes, one periampullary diverticulum and one CBD stone were found, respectively. The CBD stone had been missed by prior MRCP examination. Of 15 patients with elevated serum liver enzymes, there were 3 cases of choledocholithiasis, 4 periampullary diverticula, and 1 ampullary tumor. EUS should be the test of choice for further evaluation of CBD dilatation when index imaging is normal. Although the EUS yield is low in cases of biliary dilatation in the setting of normal serum liver enzymes, its preferential use would potentially avoid unnecessary MRCP and ERCP.

Adult↗
PubMed1982

Acute suppurative cholangitis: comparison of internal and external biliary drainage.

Forty-eight patients with acute cholangitis who presented with postcholocystectomy choledocholithiasis are reported on in this study. As soon as the general condition of the patients had improved, or as soon as the fluid balance was established, usually within 48 hours of admission, the patients were divided into two groups: group A (28 patients) under went choledochoduodenostomy, and group B (20 patients) had T-tube drainage. The results demonstrate that internal biliary drainage in patients with acute cholangitis is associated with lower mortality and morbidity, and that further recurrent choledocholithiasis is eliminated after choledochoduodenostomy, which was the drainage procedure used exclusively in this series of patients. We believe that this difference in results is due first to the elimination of the possibility of exogenous contamination through the T tube when internal drainage is used, and second to the difference in the caliber and length of th two drainage systems.

Acute Disease↗
PubMed1986

Biliary disease in pregnancy: strategy for surgical management.

Acute biliary tract disease complicated intrauterine pregnancy in 26 patients seen during a 5 year period. Biliary symptoms were distinct and occurred during the first trimester in 7 patients, the second trimester in 5 patients, the third trimester in 12 patients, and in two early postpartum patients. Nine patients had marked hyperamylasemia which resolved with medical management, and no severe cases of pancreatitis occurred. Ultrasonography was used to confirm the presence of gallstones in 18 patients and demonstrated dilated intrahepatic ducts in one of two patients with surgically proved choledocholithiasis. Nineteen patients had cholecystectomy and cholangiography, and 4 had common bile duct explorations. Only two of seven patients who presented in the first trimester had term pregnancy. Diagnosis of cholelithiasis in pregnancy by ultrasonography is accurate and reliable. The risk to the fetus of radionuclide scanning and conventional radiography is not justified. Secondary hyperamylasemia is common but responds to conservative therapy. Operation may be delayed until delivery in most patients, with urgent exploration reserved for uncertainty in diagnosis, choledocholithiasis, or acute cholecystitis that does not resolve with medical measures.

Acute Disease↗
PubMed1989

Changing spectrum of cholelithiasis and cholecystitis in infants and children.

Cholecystitis and cholelithiasis are infrequent in children and have been historically associated with adolescent pregnancy or hemolytic disorders; however, the incidence and spectrum of cholelithiasis seem to be changing. Between 1970 and 1988, 47 children 17 years of age or less underwent cholecystectomy for cholecystitis or cholelithiasis in our hospital. The patients were divided into chronologic groups: Group 1 encompassed 1970 through 1979 (15 patients) and group 2, 1980 through 1988 (32 patients). The groups were compared for age, sex, pregnancy, blood dyscrasia, family history, obesity, use of total parenteral nutrition (TPN), and incidence of choledocholithiasis with its sequelae. A significant increase in the number of patients with cholelithiasis was found. Infants and young children were affected more frequently in group 2, and many of these young patients had a history of TPN. Choledocholithiasis was also more common in group 2 and presented with life-threatening sequelae. Calculous biliary tract disease should be considered as a possible cause of abdominal pain in children. Timely operative intervention can prevent the increasingly common sequelae of childhood cholelithiasis.

Adolescent↗