Role of endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis in patients undergoing laparoscopic cholecystectomy

doi:10.1016/S0016-5107(98)70298-6

Gastrointestinal Endoscopy

Volume 47, Issue 1, January 1998, Pages 50-56

Presented, in part, at the Annual Meeting of the American Society for Gastrointestinal Endoscopy, May 19-22, 1996, San Francisco, California (Gastrointest Endosc 1996;43:399).

https://doi.org/10.1016/S0016-5107(98)70298-6 Get rights and content

Abstract

Background: We report our experience of selective cholangiography in a series of laparoscopic cholecystectomies and evaluate the strategy of using “stricter criteria” to select preoperative endoscopic retrograde cholangiopancreatography (ERCPs). Methods: A total of 1847 consecutive laparoscopic cholecystectomies were analyzed for use of cholangiography. A high risk of common bile duct stones (bilirubin level more than 2 mg/dL, jaundice, alkaline phosphatase level more than 150 U/L, pancreatitis, or dilated bile duct and/or stone on ultrasound or CT) was an indication for preoperative ERCP. Selective intraoperative cholangiography was performed for intermediate risk of bile duct stones. The strategy of using “stricter criteria” (jaundice and/or demonstrated bile duct stones on ultrasound or CT) for selecting preoperative ERCP was evaluated retrospectively. Results: Preoperative ERCP was performed in 135 patients (7.3%) and demonstrated bile duct stones in 43 (32%). Of 36 patients with mild gallstone pancreatitis alone, stones were found only in 6 patients (17%). Selective intraoperative cholangiography was performed in 87 (5%), and stones were found in 2 (2%); 67 (3.6%) postoperative ERCPs were performed for suspected choledocholithiasis, and stones were found in 21 (32%). Applying “stricter criteria” to select preoperative ERCP would predict ductal stones in 56%, whereas 3% of patients with stones would be missed, resulting in a 50% reduction in preoperative ERCPs. Conclusions: Even in selected patients considered likely to have choledocholithiasis, the diagnostic yield of preoperative ERCP is low. Using “stricter criteria” to select patients for preoperative ERCP can avoid unnecessary ERCPs. (Gastrointest Endosc 1998;47:50-6.)

Section snippets

Methods

A total of 1847 consecutive laparoscopic cholecystectomies performed in this institution from 1990 through 1995 were analyzed for use of ERCP and IOC. A high risk of common duct stones was considered an indication for preoperative ERCP and was defined as a bilirubin level of more than 2 mg/dL (normal range 0.2 to 1.2 mg/dL), an alkaline phosphatase (ALK) level of more than 150 U/L (normal range 36 to 118 U/L), jaundice or pancreatitis (either present or recent), or dilated bile duct (diameter

Results

The proportion of common bile duct stones (i.e., number of patients with stones detected at preoperative or postoperative ERCP or IOC) was 4% (70 of 1847 cholecystectomies). ERCP was performed in 208 of 1847 cases (11%).

Discussion

Although there are other reports of ERCP in patients undergoing laparoscopic cholecystectomy,2, 3, 4, 5, 6, 7, 8 ours has the largest number of patients from a single center. Even in patients considered likely to have bile duct stones, we found that the positive diagnostic yield of preoperative ERCP was low (32%). This is supported by the results of other studies in which the diagnostic yield ranged from 25% to 50%.2, 3, 4, 5, 6, 7, 8 The 7% of our laparoscopic cholecystectomy patients who

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Cited by (93)

Three modalities on management of choledocholithiasis: A prospective cohort study
2017, International Journal of Surgery
Choledocholithiasis can be managed by endoscopic retrograde cholangiopancreaticography/endoscopic sphincterotomy (ERCP/EST) or laparoscopic common bile duct (CBD) exploration by transcystic (TC) or transductal (TD) stone extraction.
The aim of this study was to evaluate the safety and effectiveness of common bile duct stones extraction by ERCP/EST, TC approach and TD approach for choledocholithiasis, with specific emphasis on ERCP/EST, TC approach versus TD approach.
Between January 2011 and June 2014, a total of 161 patients were scheduled for two-stage (preoperative ERCP/EST followed by cholecystectomy, ERCP group, n = 52)or single-stage (laparoscopic exploration of the CBD combined with cholecystectomy, n = 109) treatment for choledocholithiasis with concomitant cholecystitis. Laparoscopic common bile duct exploration was performed by TC approach (TC group, n = 63)or TD approach (TD group, n = 46). T-tube insertion was performed in selected patients. Patients were regularly followed up at bimonthly intervals or more frequently in presence of any symptom. Primary outcomes measures included length of hospital stay, successful bile duct clearance, postoperative/procedural morbidity and mortality.
Successful bile duct clearance was 100.0% in TD group, 93.7% in TC group and 92.3% in ERCP group. 4 cases in the TC group and 4 cases in the ERCP group required an extra choledocholithotomy due to impacted stones. 9 patients underwent T-tube drainage in TD group comparing to 1 case in ERCP group and no cases in TC group. Comparing to TC group, there was more postoperative morbidity in TD and ERCP group. Bile leaks were more frequent in TD group (8.7%) than TC (3.2%) and ERCP group (3.8%), which prolonged hospitalization in TD group than TC and ERCP group. 2 patients in ERCP group suffered duodenal perforation and one of them died because of the complication. However, total procedural morbidity was 0% in TC and TD group.
TD stone extraction has a higher stone clearance but with a higher risk of bile leaks. Procedural morbidity is more often happened in ERCP/EST, which may result in serious consequences. TC stone extraction, which seems an effective approach with lower complication rates, is accessible techniques simplifying the operation procedure by avoiding choledocholithotomy and subsequent T-tube insertion.
Extracorporeal shock wave lithotripsy for difficult common bile duct stones: A comparison between 2 different lithotripters in a large cohort of patients
2015, Gastrointestinal Endoscopy
Extracorporeal shock wave lithotripsy (ESWL) for difficult common bile duct (CBD) stones is a safe and effective treatment strategy allowing for bile duct clearance in approximately 90% of patients with a low incidence of mild adverse events.
To compare the CBD clearance rates achieved after ESWL performed with 2 different lithotripters (Siemens Lithostar Plus and Storz Modulith SLX-F2) in a large cohort of patients with difficult CBD stones.
A retrospective analysis of a prospectively collected database.
Tertiary care center.
All of the consecutive patients who underwent ESWL because of difficult CBD stones between 1990 and 2012 were considered suitable for inclusion.
ESWL with Lithostar Plus or with Modulith SLX-F2.
CBD clearance.
Three hundred ninety-two patients with difficult CBD stones were treated; 199 patients were treated with the Lithostar Plus and 193 patients with the Modulith SLX-F2. CBD clearance was achieved in 349 patients (89.0%) with no significant difference between the patients treated with Lithostar Plus and those treated with Modulith SLX-F2 (90.5% vs 87.6%; P = .45). Patients treated with Modulith SLX-F2 underwent a significantly lower number of ESWL sessions (3 [range, 2 to 4] vs 3 [range, 2 to 4]; P = .0015), had a lower incidence of ESWL-related adverse events (5.2% vs 13.6%; P = .009), and never required opioid analgesia (P < .001).
Retrospective design.
The Modulith SLX-F2 allows the same clearance rate as the Lithostar Plus but has a significantly lower incidence of adverse events and requires fewer ESWL sessions.
Endoscopic Retrograde Cholangiopancreatography
2014, Textbook of Gastrointestinal Radiology: Volumes 1-2, Fourth Edition
Laparoscopic common bile duct exploration and primary closure of choledochotomy after failed endoscopic sphincterotomy
2014, International Journal of Surgery
Citation Excerpt :
Beyond any reasonable doubt, the process is an important preoperative adjunct in lots of patients with choledocholithiasis, especially for those patients with retained stones [6,7]. Successful endoscopic treatment is possible in most of patients and in experienced hands duct clearance can be achieved in over 90% [8–10], though more than 25% of the patients requires two or more ERCPs [8,11]. Previous operations, cholangitis, anatomic abnormalities, stone impaction, diameter of common bile duct and size of stones were potential predictors for failure of endoscopic CBD clearance [12,13].
The aim of this study is to evaluate the safety and feasibility of laparoscopic common bile duct exploration and primary closure of choledochotomy for the patients with common bile duct stones (CBDS) who failed in endoscopic sphincterotomy (EST).
Between January 2007 and June 2012, a total of 78 patients who subjected to endoscopic retrograde cholangiopancreatography (ERCP) and EST, but failed in endoscopic stone extraction, were referred to us. The following day, laparoscopic cholecystectomy, laparoscopic common bile duct exploration (LCBDE) and primary closure of choledochotomy were performed in all patients.
No intraoperative complications were experienced in the patients. 6 patients required conversion to open cholecystectomy due to impacted stones. The mean operative time was 145 min. The mean postoperative hospital stay was 6d. All the patients achieved successful stone clearance. 13 cases had slight bile leaks, which resolved spontaneously. None of the patients experienced biliary peritonitis, biliary fistula, pancreatitis, or cholangitis.
If it is performed by experienced laparoscopic surgeons, primary closure following immediate laparoscopic common bile duct exploration (LCBDE) is safe and feasible for patients with CBDS who fail in endoscopic stone extraction.
Modern Management of Common Bile Duct Stones
2013, Gastrointestinal Endoscopy Clinics of North America
Stones in the bile duct: Endoscopic and percutaneous approaches
2012, Blumgart's Surgery of the Liver, Biliary Tract and Pancreas

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^☆: From the Division of Gastroenterology and Gastrointestinal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

^☆☆: Reprint requests: Tony C. K. Tham, MD, MRCP, Consultant Gastroenterologist, Ulster Hospital, Dundonald, Belfast, BT16 0RH, Northern Ireland, United Kingdom.

^★: 37/1/86211

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Role of endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis in patients undergoing laparoscopic cholecystectomy☆,☆☆,★

Abstract

Section snippets

Methods

Results

Discussion

Lancet

Am J Surg

Gastrointest Endosc

Gastroenterology

Gastroenterology

Gastrointest Endosc

Am J Surg

Gastrointest Endosc

Laparoscopic cholecystectomy and common bile duct stones. The utility of planned perioperative endoscopic retrograde cholangiography and sphincterotomy: experience with 63 patients

Ann Surg

Endoscopic management of bile duct stones

J Gastroenterol Hepatol

Laparoscopic cholecystectomy combined with endoscopic sphincterotomy and stone extraction or laparoscopic choledochoscopy and electrohydraulic lithotripsy for management of cholelithiasis and choledocholithiasis

Surg Endosc

An early review of 800 laparoscopic cholecystectomies at a university affiliated community teaching hospital

Am Surg