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PubMedDate not supplied

Endoscopic therapy in primary sclerosing cholangitis: outcome of treatment and risk of cancer.

BACKGROUND/AIMS: Primary sclerosing cholangitis is a cholestatic liver disease characterized by multifocal strictures in the intra- and extrahepatic biliary tree. Dominant strictures may arise in the extrahepatic bile ducts, and in these circumstances, endoscopic therapy has been introduced to relieve cholestasis and perhaps also delay the development of liver cirrhosis. The experience of endoscopic treatment at this point in time is limited and the long-term benefit is not clear. Neoplastic transformation in primary sclerosing cholangitis is unpredictable, which is illustrated in the present study along with an evaluation of the efficacy of endoscopic treatment. METHODOLOGY: Endoscopic retrograde cholangiopancreatography was performed in 25 patients with primary sclerosing cholangitis. In 15 there were dominant strictures in the hilum of the liver and/or the distal bile duct and these patients were treated by dilation and/or endoprostheses. Four patients in the treatment group had just cholestatic biochemical test results and 11 were symptomatic. RESULTS: Endoscopic therapy was technically successful in all 15 patients. In 43 sessions, 5 patients were treated by dilation, 2 with endoprostheses, and 8 by both methods. Improvement was achieved radiologically in 12 patients, clinically in 8, and according to liver function tests in 7. Therapy was complicated by cholangitis in 5 patients. Complications were mild and there was no mortality related to the procedure. However, 6 patients in the treatment group died, 5 of cholangiocarcinoma and 1 of colon cancer. CONCLUSIONS: Endoscopic therapy in primary sclerosing cholangitis is indicated in selected patients. The cancer incidence is high, not least in patients with deteriorating disease. It is important to find techniques for identifying patients at risk in order to perform liver transplantation before malignant transformation.

Adult↗
PubMedDate not supplied

Endoscopic treatment of choledocholithiasis in the era of laparoscopic cholecystectomy: prospective analysis of 386 patients.

BACKGROUND/AIMS: Endoscopic papillotomy is a well-established procedure for treating choledocholithiasis. The aim of this study is to expose our experience with this method in a prospectively collected series of 386 patients and to analyze the safety and efficacy of the pre-cut procedure. METHODOLOGY: Between October 1995 and December 1999, 760 endoscopic retrograde cholangiopancreatographies were performed in 670 patients. Of these, 449 were done to treat 386 patients with choledocholithiasis. The pre-cut technique was performed after failure of multiple cannulation attempts. RESULTS: Bile duct clearance was achieved in 344 (89.1%) cases, however the success rate would increase to 95.1%, if the cases, which endoscopic stone extraction was not feasible, were excluded. Pre-cut was performed in 31 (8.03%) patients, and 11 of them presented some procedure-related complication, while the complication rate of standard sphincterotomy was 3.9% (relative risk = 8.4; 95% confidence interval = 4.2-16.7). Overall complication rate was 6.7% (26 out of 386)--pancreatitis = 13, bleeding = 9, acute cholecystitis = 2, cholangitis = 1, guide-wire-related choledochal perforation = 1. Thirty-day mortality was 1.55% (n = 6), but procedure-related mortality was 0.25% (n = 1). CONCLUSIONS: Endoscopic papillotomy is a safe and effective procedure for patients with symptomatic choledocholithiasis. The pre-cut procedure increases the complication rate of the endoscopic approach, and should be restricted to cases, in which an endoscopic intervention is mandatory.

Adolescent↗
PubMed1996

Endoscopic repair of frontal sinus fracture: case report.

Although the benefits of endoscopic techniques including direct visualization as well as minimization of scars and morbidity have been employed in general, gynecological, and thoracic cases, only recently have plastic surgeons begun to champion endoscopic procedures in their practices. The authors describe an endoscopic procedure that reduces an anterior wall frontal sinus fracture through two 1.0 cm paramedian stab incisions located less than 1.0 cm behind the hairline of a 13-year-old female patient. The repair, performed in the bloodless subperiosteal plane, was executed with a 30 degrees endoscope and endoscopic instrumentation. The patient had restoration of her cosmetic deformity and no postoperative morbidity. To the authors' knowledge, this represents the first description of endoscopic repair of a traumatic frontal bone defect.

Adolescent↗
PubMed2002

Feasibility and complications of endoscopic biliary drainage in patients with malignant biliary obstruction at King Chulalongkorn Memorial Hospital.

Currently the best curative therapy for primary malignant biliary tumor is surgery. Unfortunately, many patients present at a very late stage and only palliative biliary drainage is possible. Usually nonsurgical palliative biliary drainage means either percutaneous or endoscopic approach. In this series, the authors reported the rate of technical success and immediate complications in patients with malignant biliary obstruction who underwent endoscopic biliary drainage. From endoscopic retrograde cholangiopancreatography (ERCP) database between September 2000 and October 2001, there were 273 ERCP performed for obstructive jaundice. Of these, 50 patients with malignant tumor underwent 80 procedures for endoscopic biliary drainage. The patients were divided into three groups according to the cholangiographic findings and clinical diagnoses. Patients with carcinoma of the pancreatic head were categorized as group I (n=10). Group II (n=20) and III (n=20) were patients with extrahepatic cholangiocarcinoma and hilar cholangiocarcinoma respectively. All patients received either plastic or metallic endoprothesis placement for biliary drainage. All patients except two in group I had successful endoscopic treatment. Complications in group I, II and III were 15.4 per cent, 14.3 per cent and 53.1 per cent respectively. Only one patient in group II developed significant hypotension during the procedure. Another complication was defined as post procedure cholangitis. In conclusion endoscopic biliary drainage was technically feasible in 97.5 per cent of patients who had malignant biliary obstruction. In patients with hilar tumor the incidence of post procedure cholangitis was high (53.1%). Improvement in technique, avoiding unnecessary contrast injection, and draining the obstructed bile duct after injecting the contrast may improve the outcome and decrease the rate of post procedure cholangitis in these patients.

Aged↗
PubMedDate not supplied

Endoscopic management of bile duct injuries in 107 patients: experience of a Saudi referral center.

BACKGROUND/AIMS: Management of postcholecystectomy complications has been variably discussed. Various options exist but the recent trend has been towards the endoscopic retrograde approach favoring a simultaneous diagnostic and therapeutic potential. We studied the various endoscopic modalities to evaluate the efficacy of this approach. METHODOLOGY: A retrospective analysis was conducted of 318 patients referred to the endoscopy department for suspected postcholecystectomy complications. A total of 107 patients were identified to have biliary injury. The study period extended from May 1982 to April 2000. All cases of bile duct injury were evaluated by endoscopic retrograde cholangiopancreatography for the feasibility of offering therapy. RESULTS: From a total of 107 cases, 123 sites of biliary injury were identified. There were 66 patients with benign strictures and 57 patients with leaks and another 16 patients had a combination of leaks and strictures. Endoscopic diagnosis was feasible in 98% of patients. Subsequently, 81 patients accounting for 76% of the cases were considered for endotherapy and successful healing was shown in 90%. Seventy-seven percent of the leaks underwent trial of endoscopic management with successful response seen in 93.2% cases. Similar results occurring for strictures where 87.2% maintained sustained dilatation from a total of 45 case that had attempted endotherapy. There were no complications encountered in any of the patients. CONCLUSIONS: Endoscopic retrograde cholangiopancreatography is a safe and feasible mode of therapy for patients presenting with suspected bile duct injuries. This form of intervention should be considered as the initial step in the diagnosis and treatment of postcholecystectomy complications.

Bile Ducts↗
PubMedDate not supplied

Combined percutaneous and endoscopic procedures for bile duct obstruction: simultaneous and delayed techniques compared.

BACKGROUND/AIMS: In patients with obstructive jaundice, when the endoscopic approach fails to achieve biliary drainage, percutaneous cannulation and combined endoscopic/percutaneous endoprosthesis insertion can be performed simultaneously or in stages. This study compared these two approaches. METHODOLOGY: Over a three-year period 41 patients were studied. All had obstructive jaundice for which endoscopic drainage had failed. In 22 patients (group 1) percutaneous transhepatic drainage was followed a few days later by combined endoscopic and percutaneous procedure. In 19 patients (group 2) the percutaneous transhepatic drainage and combined drainage were performed at the same session. In the multiple stage group the mean interval between the first endoscopic retrograde cholangiopancreatography and final combined procedure was 9 days (SD 5.2). The groups were similar for sex, underlying pathology and reasons for failure of endoscopic approach. Group 1 patients were older 73 vs. 65 years (p < 0.05). RESULTS: Patients in group 2 had a more rapid recovery and discharge home: mean 6 days, compared to mean 18 days from the initial procedure for group 1 (p < 0.001). Five patients died of their disease without leaving hospital (4 in group 1, 1 in group 2). In each group drainage failed in 1 patient. Complications were more common in group 1: 73% vs. 37% (p < 0.05). Pancreatitis (3 vs. 2) and septicemia (4 in group 1, 3 in group 2) were similar but group 1 had complications from the external drain: cholangitis and pyrexia in 4 patients, 3 bile leaks, and 1 catheter displacement. CONCLUSIONS: When endoscopic drainage alone fails, a combined percutaneous/endoscopic procedure should only be performed if it can be carried out simultaneously.

Aged↗
PubMedDate not supplied

Possible risks in combining endoscopic and surgical therapy of bleeding peptic ulcers.

BACKGROUND/AIMS: Today's therapy of bleeding peptic ulcers consists of pharmacological hemostasis, endoscopic therapy and surgery in chronological order. The aim of this study was to objectively assess the contribution of the contemporary algorithm of therapy with the use of endoscopic and surgical hemostasis techniques for the therapy of bleeding peptic ulcers. METHODOLOGY: This study is a retrospective analysis and comparison of two randomized groups A/B with 427/388 patients with endoscopically verified bleeding from peptic ulcer lesions Forrest I-IIb. Patients in group A (1990-1993) were treated without endoscopic intervention, compared with group B patients (1998-2001) who were treated with endoscopic intervention. In both groups we have statistically scored and compared: quantitative operative therapy share, time interval from the beginning of therapy until surgery, APACHE II score of patients at the beginning of therapy and on the day of surgery, complications requiring re-operation and mortality. RESULTS: In groups A/B surgical hemostasis was required in 15.0/10.6% cases, from which 90.6/61.0% operations were resections and bionomic operations. Data evaluation of APACHE II scores from both groups at the beginning of treatment showed no significant difference, but at the time of operative therapy the APACHE II scores were significantly higher in group B (11.83 +/- 6.49/15.00 +/- 4.36). The length of unstable intervals of bleeding in group B compared to group A was quantitatively lengthened (A = 55.6 +/- 19.8/B = 68.6 +/- 37.0 h). Significant differences were also noted in the number of re-operations 7.8/9.8% and mortality 15.6/24.3% between groups A/B. CONCLUSIONS: The contemporary accepted sequence of hemostatic therapy is accompanied by the risks of limited selection of optimal methods of endoscopic therapy, protracting the interval of bleeding with unfavorable rise in APACHE II score, and hesitancy in indication for surgery in intractable bleeding after non-surgical therapy.

APACHE↗
PubMed2003

Endoscopic biliary drainage for biliary obstruction.

OBJECTIVE: To improve the successful rate of endoscopic biliary drainage. METHODS: Three hundred and fifty-two patients with biliary obstruction were given biliary drainage via duodenoscope from January 1998 to December 2002. 258 patients received endoscopic naso-biliary drainage (ENBD), 51 endoscopic retrograde biliary drainage (ERBD), and 43 endoscopic metal biliary endoprothesis (EMBE). RESULTS: Of the 352 patients with biliary obstruction, 337 succeeded in drainage by endoscopy and 15 failed. Ten ENBD failed patients were handled successfully by readjustment of the site of the naso-biliary tube. In 3 ERBD failed patients, 2 were given plastic stents with appropriate length and got a fluent drainage. Percutaneous transhepatic biliary drainage (PTBD) was performed in one patient after failure of endoscopic management. In 2 patients with failed EMBE, one stent could not exceed the site of tumor stricture and one was obstructed by tumor implantation only one month after EMBE. Placement of another metallic stent and a plastic stent through the previous prothesis for each patient ensured a successful drainage. CONCLUSIONS: The effect of endoscopic biliary drainage for biliary obstruction is definite. Drainage failure can be avoided or remedied as early as possible by taking some active measures.

Adolescent↗
PubMed2004

Outcome of endoscopic minor papillotomy in patients with symptomatic pancreas divisum.

CONTEXT: Pancreas divisum has been associated with recurrent acute pancreatitis, chronic abdominal pain without elevated pancreatic enzymes, and chronic pancreatitis. Prior studies suggest that endoscopic minor papillotomy benefits certain symptomatic pancreas divisum patients. However, the data are quite limited and there is a lack of long-term follow-up. OBJECTIVE: To describe a retrospective study of endoscopic minor papillotomy for pancreas divisum. PATIENTS: Eighty-nine adult patients who underwent endoscopic minor papillotomy at our referral center were included in the study. Median follow-up was 29 months. INTERVENTION: We conducted a telephone survey. Fifty-three patients were available for the telephone survey. RESULTS: Thirty-two patients (60.4%) reported immediate improvement: however, symptoms recurred in 17 (53.1% of the immediate responders). Repeat endoscopic interventions were performed in 8 patients, with long-term improvement in two. Overall long-term improvement was achieved in 17 patients (32.1%). Results of minor papillotomy were more favorable for patients with recurrent, well-defined bouts of pancreatitis (immediate improvement: P=0.036; long-term improvement: P=0.064) compared to those with pancreatitis who reported continuous pain and those without clinical evidence of pancreatitis (immediate improvement: 73.3%, 42.9% and 44.4%, respectively; long-term improvement: 43.3%, 21.4%, and 11.1%, respectively). CONCLUSIONS: The long-term benefit from endoscopic minor papillotomy using strict criteria is poorer than suggested from previous studies. However, pancreas divisum patients with well-defined bouts of pancreatitis are more likely to benefit from endoscopic minor papillotomy than those without symptom-free intervals between "attacks" and those with pain that is not associated with elevated pancreatic enzymes.

Abdominal Pain↗
PubMed2004

Light fields for minimal invasive surgery using an endoscope positioning robot.

OBJECTIVES: To generate a fast and robust 3-D visualization of the operation site during minimal invasive surgery. METHODS: Light fields are used to model and visualize the 3-D operation site during minimal invasive surgery. An endoscope positioning robot provides the position and orientation of the endoscope. The a priori un-known transformation from the endoscope plug to the endoscope tip (hand-eye transformation) can either be determined by a three-step algorithm, which includes measuring the endoscope length by hand or by using an automatic hand-eye calibration algorithm. Both methods are described in this paper and their respective computation times and accuracies are compared. RESULTS: Light fields were generated during real operations and in the laboratory. The comparison of the two methods to determine the unknown hand-eye transformation was done in the laboratory. The results which are being presented in this paper are: rendered images from the generated light fields, the calculated extrinsic camera parameters and their accuracies with respect to the applied hand-eye calibration method, and computation times. CONCLUSION: Using an endoscope positioning robot and knowing the hand-eye transformation, the fast and robust generation of light fields for minimal invasive surgery is possible.

Algorithms↗
PubMed2006

Argon plasma coagulation and the future applications for dual-mode endoscopic probes.

Argon plasma coagulation (APC) is a thermoablative technique increasingly being used in endoscopy. Since its introduction, the flexible APC probe has been employed by endoscopists throughout the world. APC has helped change the endoscopic management of many gastrointestinal (GI) diseases, including hemorrhagic proctitis, watermelon stomach, bleeding peptic ulcer, and colonic varices. Endoscopists and surgeons are creatively combining standard and new electrosurgical techniques with APC. For instance, APC used in combination with piecemeal polypectomy, endoscopic mucosal resection, balloon dilatation for strictures, and plasma welding of bleeding vessels after sclerotherapy injection are among the recent innovative techniques reported. Other emerging innovations using APC that are being considered include endoscopic en bloc resection of mucosal and submucosal tumors of the GI tract, endoscopic mucosal resection supplemented with APC for high-grade dysplasia and early GI cancers, endoscopic repair of anastomotic strictures, and welding GI fistula tracts. As such, endoscopists require more efficient and cost-effective multifunctional thermoablative probes. This review discusses the development and the potential application of dual-mode plasma endoscopic probes in fulfilling these emerging needs.

Argon↗
PubMed2005

Powered Endoscopic Nasal Septal Surgery.

While nasal endoscopy is typically used for diagnosis and sinus surgery, endoscopy can be combined with powered instrumentation to perform nasal septal surgery. Powered Endoscopic Nasal Septum Surgery (PENSS) is an easy, effective and quick alternative to traditional headlight approaches to septoplasty. PENSS limits the dissection to the area of the deviation and markedly reduces the extent of subperichondrial dissection. This is particularly valuable in patients who have undergone prior septal cartilage resection. PENSS was used in 2,730 patients over 8 years. Surgical indications and technique are discussed. These patients had either isolated nasal septal deformities associated with other rhinologic pathology (sinusitis, adenoid hypertrophy polyps and external nasal deformity). PENSS was utilized with video assistance to allow an enhanced view of the endoscopic operative field. These patients were operated upon in an outpatient surgical suite and were seen for a post-operative video endoscopic evaluation at 5, 10, 15 and 20 days after surgery. The patients who had associated functional endoscopic sinus surgery were evaluated as needed until 6 weeks after surgery. There were no delayed complications. Endoscopic resection of septal spurs, deformities and deviations can be performed safely alone or in combination with endoscopic sinus surgery with minimal additional morbidity.

Adolescent↗
PubMedDate not supplied

Aggressive endoscopic hemostasis for severe gastrointestinal bleeding in critically ill patients to decrease mortality.

BACKGROUND/AIMS: In critically ill patients, with gastrointestinal (GI) bleeding achieving endoscopic hemostasis has been reported to be often difficult, with a high rebleeding rate. The purpose of this study was to examine the efficacy of endoscopic hemoclipping for severe GI bleeding in critically ill patients. METHODOLOGY: This prospective study was performed at the Department of Traumatology and Critical Care Medicine, Kyorin University Hospital from June 1996 to December 1999. Patients with predefined clinically significant GI bleeding were treated using an established endoscopic hemoclipping protocol that covered indications and procedures. RESULTS: A total of 1429 patients were enrolled in this study. Of 11 hospitalized cases meeting the definition of severe GI bleeding, it occurred at 12.3 +/- 3.9 days (mean +/- SD) after admission. Initial hemostasis was possible in all patients. Although rebleeding was seen in 1 patient, the permanent hemostasis rate by additional endoscopic hemostasis was 100%. Of the 11, 9 patients were discharged and there were 2 hospital deaths. The direct cause of death depended on the degree of underlying critical illness and combined severe pneumonia. Complications caused by endoscopic hemostasis were not seen in any patient. CONCLUSIONS: Endoscopic hemostasis is useful in critically ill patients with the severe GI bleeding that occurs during critical care in the intensive care unit.

APACHE↗
PubMed1991

Cleaning, disinfection, and sterilization of gastrointestinal endoscopes: approaches in the office.

Bacterial contaimination of endoscopes can be clinically significant. While current data suggest that flexible sigmoidoscopy may entail fewer risks than upper endoscopy, these data are too incomplete to draw this conclusion. Careful cleaning and disinfection after each procedure are recommended. Gas sterilization of the endoscope and gas or heat sterilization of accessory equipment may be necessary in certain clinical situations. It must be remembered that hundreds of thousands of endoscopic procedures were performed in the 1970s using cleaning only without substantial health risk. The processes do not have to be complicated or difficult. Staff must be well trained and must understand the potential risks of working with disinfecting agents such as alkaline glutaraldehyde. It is recommended that the clinician fully understand the cleaning and disinfection steps and be able to perform them. It is important that office procedures be based on efficacy, not convenience. The procedures developed to date are not ideal and the ideal disinfectant has yet to be found. Cleaning and disinfecting machines have been developed, but they are expensive and their efficacy and safety are no better than hand-performed methods. An alternative approach to reducing transmission of infections by endoscopes may be to seek less adherent plastic substances for the endoscope sheath. The introduction of immersible endoscopes has helped with cleaning, but their use may also give rise to a false sense of security. Diligent attention to cleaning and disinfection is still necessary.(ABSTRACT TRUNCATED AT 250 WORDS)

Detergents↗
PubMed1990

[The endoscopic treatment of large calculi in the choledochus. The preliminary results with intracorporeal electrohydraulic shock-wave lithotripsy].

Results are reported of endoscopic treatment of: 236 patients with common bile duct calculi treated by endoscopic sphincterotomy with or without hydrostatic balloon extraction and extraction of the calculi, mechanical lithotripsy and endoprosthesis; preliminary results in 12 patients treated by intracorporeal electrohydraulic lithotripsy. Complete removal of calculi from the common bile duct was achieved in 171 of 236 sphincterotomized patients (72 per cent). Complications were observed in 11 per cent of the patients. Mechanical cracking of common bile duct calculi was realized in 60 of 65 patients (92 per cent) with complications observed in 3 per cent. Thus, with the use of mechanical lithotripsy the success of endoscopic treatment rose to 98 per cent, without increase in the incidence of complications. Seven patients had endoprostheses placed because of failure to extract the calculi. Intracorporeal electrohydraulic lithotripsy was performed in 12 patients with common bile duct lithiasis (4 with single and 8 with numerous stones with diameter 20-40 mm. In one patient transient acute pancreatitis was observed. A rise in serum amylase content was recorded in 9 patients. The stones in the common bile duct were effectively broken to pieces and removed in 8 patients. Lithotripsy was unsuccessful in 4 patients, two of whom had solid calcium depositions. In the common bile duct of the other two MTBE gas applied. The patients were subjected to repeated lithotripsy with positive effect. It is pointed out in conclusion that crushing stones in the common bile duct allows real improvement of the results of endoscopic sphincterotomy in common bile duct calculosis. Endoscopic treatment of larger calculi became also feasible which until a few years ago were contraindication for endoscopic treatment.

Aged↗
PubMed1984

Specifications of endoscopic ultrasonography.

In this paper we are going to describe the specifications of endoscopic ultrasonography using the equipment type III (Olympus GF- UMI ) on a basis of experiences in 45 patients during the past one year. The main body of the instrument is a standard type of gastroscope, Olympus GF-B3. The ultrasonic probe is incorporated into the tip of the endoscope. This instrument makes possible endoscopic visualization of the UGI tract and, at the same one time, allows us to do ultrasonic scanning of internal organs in the neighbourhood of the UGI tract. The better resolution of ultrasonic image is definitely obtained with this instrument than that of the conventional ultrasonography because its ultrasonography is intraluminally performed with high frequency transducer of 7.5 MHz and the image is never disturbed by the gastroduodenal gas nor the abdominal wall tissues. Endoscopic ultrasonography using the equipment type III is useful as a new diagnostic tool of great value in gastroenterology. However, there still remain a few mechanical points to be improved. It is desired that the rigid section of the tip of the endoscope is shortened more and the stability of the endoscopic image is guaranteed. These improvements would heighten its diagnostic value.

Cystadenoma↗
PubMedDate not supplied

Endoscopic adrenaline injection in treatment of bleeding peptic ulcers.

This study aimed to compare the results of bleeding peptic ulcer treated by endoscopic adrenaline injection with controls treated conventionally. Between January 1991 and December 1993, 69 patients with actively bleeding peptic ulcers with visible vessel received endoscopic adrenaline injection. This group of patients was compared with 31 endoscopically similar patients treated conventionally, using H2 blockers with or without surgery, from October 1987 to December 1990 prior to the introduction of endoscopic injection therapy in this hospital. Both groups of patients were comparable in terms of age, haemoglobin level on admission and site of ulcer (gastric or duodenal). Permanent haemostasis was attained with endoscopic adrenaline injection in 97% of our patients. Rebleeding occurred in 9% in the injected group vs 39% in the historical control group (p < 0.005). Three percent of patients in the injected group had emergency surgery compared with 48% in the control group (p < 0.005). The median hospital stay and transfusion requirements in the injected group were 6 days and 2 units respectively vs 8 days and 3 units in the control group but the difference was not statistically significant. We conclude that endoscopic adrenaline injection is effective in the treatment of bleeding peptic ulcer leading to a reduction in rebleeding rate and emergency surgery.

Adult↗
PubMed1996

Management of bile duct stones in the era of laparoscopic cholecystectomy: appraisal of routine operative cholangiography and endoscopic treatment.

OBJECTIVE: To assess the value of preoperative or postoperative endoscopic treatment of bile duct stones and routine use of operative cholangiography (OC) for detection of unsuspected common bile duct (CBD) stones in conjunction with laparoscopic cholecystectomy. DESIGN: Prospective study. SETTING: University hospital, Sweden. MAIN OUTCOME MEASURES: Diagnostic and therapeutic yield of stones at endoscopic retrograde cholangiography (ERC) before or after laparoscopic cholecystectomy and routine operative cholangiography. RESULTS: Of 630 patients who underwent laparoscopic cholecystectomy, 84 had preoperative ERC. Of these 84, 47 (56%) had bile duct stones. Endoscopic sphincterotomy was done for all 47, of whom 3 (6%) had retained stones at OC. OC was done for 590 (94%) of the 630 patients, and 45 (7.6%) were found to have choledocholithiasis. At postoperative ERC, however, 10 of these patients were free of stones and there were two cases of false negative OC, which resulted in sensitivity and specificity of OC of 95% and 98%, respectively. Thus, 35 patients (6%) had bile duct stones discovered at OC, of whom 33 had "unsuspected" stones. Of these 35 patients, 29 were cleared endoscopically after cholecystectomy. The remaining 6 patients were cleared of stones either by open choledocholithotomy (n = 2) or by laparoscopic transcystic manipulation (n = 4). There was no mortality after diagnostic or therapeutic ERC, and morbidity was confined to two cases each of pancreatitis and cholangitis, which resulted in a complication rate of 3% (4/118). No complications resulted from IOC. CONCLUSIONS: Preoperative ERC should be done for patients with symptoms or findings indicating ductal calculi. In most patients undergoing laparoscopic cholecystectomy, OC is feasible and its routine use is strongly advocated. Bile duct stones diagnosed at OC can safely and successfully be treated endoscopically after laparoscopic cholecystectomy. Until laparoscopic bile duct exploration becomes routine and generally applicable, endoscopic management of bile duct stones both before and after cholecystectomy will be an important therapeutic option.

Cholangiography↗