Invited commentary to: “Laparoscopic cholecystectomy—How to diagnose common bile duct stones?”

Krähenbühl, L.; Büchler, Markus W.

doi:10.1007/bf02602614

Acta Chir Austriaca

1996

DOI: 10.1007/bf02602614

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Invited commentary to: “Laparoscopic cholecystectomy—How to diagnose common bile duct stones?”

L. Krähenbühl

Markus W. Büchler

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1997

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Cited by 1 publication

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“…The same might apply for the experience of endoscopists in dealing with poor results (80%) on flexible endoscopic stone extraction (ESE), as Cotton [4], Rieger [8] Krähen-bühl and Büchler [6], Bonatsos [2], Coppola [3], Boeckl [1], and Sungler [9], documented an extraction rate of 95% up to 100%.…”

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confidence: 94%

EAES ductal stone study

Sungler¹,

Boeckl²

1997

Surg Endosc

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We congratulate the authors for this prospective randomized trial comparing two-stage vs single-stage management of ductal stones (CBDS) in the era of laparoscopic cholecystectomy. Nevertheless, we look at the data and some of the literature reports-partly not mentioned in this paper-a little differently.As stated in this paper, the participating surgeons had varying experience in laparoscopic stone clearance. The same might apply for the experience of endoscopists in dealing with poor results (80%) on flexible endoscopic stone extraction (ESE), as Cotton [4], Rieger [8] Krähen-bühl and Büchler [6], Bonatsos [2], Coppola [3], Boeckl [1], and Sungler [9], documented an extraction rate of 95% up to 100%.The rate of unnecessary endoscopic retrograde cholangiography (ERC) in group A is fairly low, as only the presence of stones is mentioned and no other pathology like benign papillary stenosis or signs of passed stones are recorded. Group B encountered 17% more CBDS, a fact raising concern and suggesting that at least some of these stones were air bubbles on intraoperative cholangiogram and consequently easy to treat laparoscopically-as already concluded earlier by McSherry on a similar occasion [7]. With ESE one or more stones are virtually and directly visualized on extraction; in laparoscopic duct clearance at least some of the suspected ''stones-air bubbles'' are only flushed or pushed through the papilla without evidence of their substantial nature.Changing only the criticized data for ESE in group A and the numbers and implications of the questionable cholangiograms in group B in Table 6 [5], the results and conclusions substantially change and definitely favor the twostage procedure, not to mention the conversion rate of 16% in group B.Thus the role of ERC should not change to selective use after laparoscopic cholecystectomy, as the prospects of postoperative ESE in the operating room at the end of a frustrating laparoscopic procedure is a nightmare for every busy unit, as one operating room might be blocked for hours-not to mention whether an experienced endocopist would be available at that moment.The authors' goal-namely, to accomplish all the necessary biliary procedures at the time of laparoscopic surgery-is most desirable, but so far not at all proven to be superior to a two-stage procedure.Laparoscopic common bile duct exploration requires additional instrumentation and a caseload to acquire the skills; otherwise, the incidence of injury will be unacceptably high [7]. The same applies for ESE, and the question arises, where surgical endoscopists should get their routine and experience, when only called into the operating theaters for the most difficult last option procedures, if laparoscopy has failed.We therefore conclude that the ''therapeutical splitting'' with selective preoperative ERC is certainly at present the standard procedure and laparoscopic duct exploration is limited to incidental cases with false-negative preoperative diagnostics.

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mentioning

confidence: 94%

EAES ductal stone study

Sungler¹,

Boeckl²

1997

Surg Endosc

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Invited commentary to: “Laparoscopic cholecystectomy—How to diagnose common bile duct stones?”

Cited by 1 publication

References 10 publications

EAES ductal stone study

EAES ductal stone study

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