Management of Preoperatively Suspected Choledocholithiasis: A Decision Analysis

Kharbutli, Bilal; Velanovich, Vic

doi:10.1007/s11605-008-0624-6

Cited by 74 publications

(50 citation statements)

References 33 publications

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“…28 CBD stones are responsible for considerable morbidity and mortality from complications including pancreatitis, cholangitis and hepatic dysfunction. To prevent such complications, some authors recommend routine intra-operative cholangiogram to exclude unsuspected CBD stones, while undertaking laparoscopic cholecystectomy.…”

Section: Discussionmentioning

confidence: 99%

Prospective evaluation of a selective approach to cholangiography for suspected common bile duct stones

Horwood

Akbar

Davis

et al. 2010

annals

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Ann R Coll Surg Engl 2010; 92: 206-210 206Common bile duct (CBD) stones remain a considerable source of morbidity and mortality, and their presence should be considered in all patients presenting with symptomatic calculi. Intra-operative cholangiography (IOC) has been shown to be a sensitive and specific method of demonstrating bile duct stones; 1 however, it is time consuming, has resource implications and may result in unnecessary bile duct explorations due to false-positive examinations.Other methods for pre-operative assessment of the CBD have previously been evaluated. Magnetic resonance cholangiopancreatography (MRCP) is a sensitive, non-invasive method of imaging the biliary tree.2,3 However, it lacks the immediate therapeutic options available during IOC or endoscopic retrograde cholangiopancreatography (ERCP) and consumes the valuable MRI resource. ERCP, however, is an invasive procedure with morbidity and mortality rates Common bile duct (CBD) stones can cause serious morbidity or mortality, and evidence for them should be sought in all patients with symptomatic gallstones undergoing cholecystectomy. Routine intra-operative cholangiography (IOC) involves a large commitment of time and resources, so a policy of selective cholangiography was adopted. This study prospectively evaluated the policy of selective cholangiography for patients suspected of having choledocholithiasis, and aimed to identify the factors most likely to predict the presence of CBD stones positively. PATIENTS AND METHODS Data from 501 consecutive patients undergoing laparoscopic cholecystectomy (LC) for symptomatic gallstones, of whom 166 underwent IOC for suspected CBD stones, were prospectively collected. Suspicion of choledocholithiasis was based upon: (i) deranged liver function tests (past or present); (ii) history of jaundice (past or present) or acute pancreatitis; (iii) a dilated CBD or demonstration of CBD stones on imaging; or (iv) a combination of these factors. Patient demographics, intra-operative findings, complications and clinical outcomes were recorded. RESULTS Sixty-four cholangiograms were positive (39%). All indications for cholangiogram yielded positive results. Current jaundice yielded the highest positive predictive value (PPV; 86%). A dilated CBD on pre-operative imaging gave a PPV of 45% for CBD calculi; a history of pancreatitis produced a 26% PPV for CBD calculi. Patients with the presence of several factors suggestive of CBD stones yielded higher numbers of positive cholangiograms. Of the 64 patients having a laparoscopic common bile duct exploration (LCBDE), four (6%) required endoscopic retrograde cholangiopancreatography (ERCP) for retained stones (94% successful surgical clearance of the common bile duct) and one (2%) for a bile leak. Of the 335 patients undergoing LC alone, three (0.9%) re-presented with a retained stone, requiring intervention. There were 12 (7%) requiring conversion to open operation. CONCLUSIONS A selective policy for intra-operative cholangiography yields acceptably high positive ...

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Section: Discussionmentioning

confidence: 99%

Prospective evaluation of a selective approach to cholangiography for suspected common bile duct stones

Horwood

Akbar

Davis

et al. 2010

annals

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“…Hamad et al performed a retrospective analysis of 2714 adult cases, of these cases only 0.18% (n=5) required surgical intervention of bile duct injury. Efficacy and safety of OTC has also been brought into question, with a decision analysis by Kharbutli et al demonstrating the increased risk of morbidity and mortality for LC following a positive OTC [18]. In a systematic review by Metcalfe et al of 4209 LC procedures in adults, the total false positive rate of OTC was encouragingly low, at 0.8% (n=34); however, the researchers suggested that R-OTC promotes the unnecessary instrumentation of patients, as 25% of asymptomatic CBD stones have been shown to pass through the sphincter of Oddi in the interim between OTC and post-operative ERCP [19].…”

Section: Discussionmentioning

confidence: 99%

Evaluation of Routine on Table Cholangiography in Paediatric Cholecystectomy

Gurprashad¹

2017

AJP

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Abstract:The use of on table cholangiogram (OTC) during laparoscopic cholecystectomy (LC) continues to be a debated topic within surgical practice. Current National Institute for Health and Care Excellence (NICE) guidelines do not advocate its routine use in adult patients, and there is scarce evidence for its use in paediatric cases. We aimed to analyse the outcomes of OTC during laparoscopic cholecystectomy to see if the NICE guidance holds true for children. A retrospective case note review was performed with IRB approval of all children who underwent laparoscopic cholecystectomy between February 2005 and November 2014. A total of 65 patients were identified, 41 female (63%) and 24 male (37%). The median age was 12 years (IQR 6). None of the patients underwent OTC during their LC. Instead, pre-operative ultrasound scan (USS) was performed in all cases. From the cohort, 5 patients (13%) showed abnormalities; 3 of which had a dilated common bile duct, and 2 of which had bile duct stones. All 5 patients went on to receive additional imaging, 2 patients underwent a repeat USS both of which were normal on review; 1 patient had an Endoscopic Retrograde Cholangio-Pancreatectography (ERCP), stent and follow-up Magnetic Resonance Cholangio-Pancreatograthy (MRCP) which was normal; 1 patient had an MRCP, ERCP with sphincterotomy and a follow-up USS which was normal; and 1 patient had an ERCP with follow-up USS which was also normal. In line with current NICE guidance for adults, our study indicates that patients with common bile duct (CBD) stones or a dilated CBD can be identified and managed prior to laparoscopic cholecystectomy. This would suggest that there is no requirement for OTC in children. Similar NICE guidance in Paediatrics may be necessary to avoid unnecessary intervention.

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“…In these cases the use of methods to achieve stone fragmentation increases the effectiveness of LCBDE. 1,2 The first experience using laser lithotripsy for the treatment of bile duct stones is attributed to Orii et al 12 in 1983, who reported 8 patients with intrahepatic stones and 3 patients with choledocholithiasis treated with an yttriumaluminum-garnet laser. The procedure was performed shortly after the ineffectiveness of the endoscopic treatment was shown.…”

Section: Discussionmentioning

confidence: 99%

“…When ERCP is inefficient because of intrahepatic or large impacted stones in the bile duct, the next step is surgical exploration of the biliary tract. 1 We have shown the effectiveness of laparoscopy in the management of choledocholithiasis. In patients in whom ERCP is ineffective, the laparoscopic conversion rate increases mainly because of impacted stones that require complex management.…”

Section: Introductionmentioning

confidence: 98%

Robot-Assisted Surgery and Holmium Laser in Complex Choledocholithiasis

Sánchez

Rodríguez

Sánchez

et al. 2015

CRSLS

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Introduction: Unsolved choledocholithiasis by endoscopic retrograde cholangiopancreatography is a complicated condition to manage. The incorporation of robotic surgery, a choledochoscope, and a holmium laser as therapeutic tools is likely to increase surgery effectiveness. Our purpose is to present the first Latin American case report of the combined use of these tools to extract a large impacted bile duct stone.

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Management of Preoperatively Suspected Choledocholithiasis: A Decision Analysis

Cited by 74 publications

References 33 publications

Prospective evaluation of a selective approach to cholangiography for suspected common bile duct stones

Prospective evaluation of a selective approach to cholangiography for suspected common bile duct stones

Evaluation of Routine on Table Cholangiography in Paediatric Cholecystectomy

Robot-Assisted Surgery and Holmium Laser in Complex Choledocholithiasis

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