Diagnosis Of Choledocholithiasis Research Articles

ERCP (endoscopic retrograde cholangiopancreatography) and EUS (endoscopic ultrasonography) in diagnosis of choledocholithiasis – battle or cooperation?

Introduction: Diagnosis of choledocholithiasis, a common manifestation of gallstone disease, is mainly based on advanced endoscopic techniques such as ERCP and EUS. Since the 1970s, ERCP has been a key method in the diagnosis and treatment of choledocholithiasis, allowing direct visualization and therapeutic interventions. However, technological developments have brought the emergence of EUS as a complementary tool, providing high-resolution imaging of the bile ducts. Understanding the diagnostic accuracy, therapeutic options and complications of both modalities is key to optimizing the care of patients with bile duct stones. Aim of the study: The aim of our study is to review and compare various diagnostic methods of bile duct stones, as well as to assess their effectiveness, accuracy, and potential complications. Materials and methods: We searched electronic sources, aspecially in the PubMed and Google Scholar databases, using keywords such as ,,endoscopic ultrasonography”, ,,endoscopic retrograde cholangiopancreatography” and ,,choledocholithiasis”. Conclusions: With the use of modern technologies, such as endoscopic ultrasonography (EUS) and retrograde choleangiopancreatography (ERCP), it has become possible to diagnose bile duct stones more accurately and introduce more effective and less invasive therapies. The development of the availability of diagnostic tests, especially those that do not require invasive procedures, has helped reduce the risk of complications. EUS may be the preferred tool of choice for patients with gallstones, as it is associated with a lower risk of complications compared to ERCP alone. Decisions regarding the use of specific diagnostic and therapeutic modalities should be made on a case-by-case basis, taking into account medical and economic considerations.

Choledochoscopy in the laparoscopic treatment of patients with choledocholithiasis: a single-centre study

Choledochoscopy is a minimally invasive procedure used for laparoscopic bile duct exploration and the removal of bile duct stones. However, there is insufficient information available about its advantages in diagnosing choledocholithiasis and its role in laparoscopic choledocholithoextraction.
 Objective — to compare the diagnostic efficacy of imaging techniques and choledochoscopy in patients with choledocholithiasis and to evaluate the role of choledochoscopy in laparoscopic choledocholithoextraction.
 Materials and methods. The study examined the results of 128 patients with calculous cholecystitis and choledocholithiasis who had laparoscopic choledocholithoextraction in combination with choledochoscopy. We assessed the sensitivity and specificity of ultrasound, CT, and MRI in the diagnosis of choledocholithiasis, as well as the efficacy of one‑stage treatment of calculous cholecystitis and choledocholithiasis using choledochoscopy and laparoscopic choledocholithoextraction.
 Results. Imaging techniques demonstrated limited sensitivity and specificity in determining the diameter and number of common bile duct stones. A total of 89 (69.5%) patients achieved complete bile duct clearance after blind laparoscopic choledocholithoextraction: 86 (81.1%) had choledochotomy, and 3 (13.6%) underwent transcystic common bile duct exploration. The combination of choledochoscopy and laparoscopic choledocholithoextraction ensured the complete removal of bile duct stones in 97.6% of patients.
 Conclusions. The imaging techniques used for determining the number of common bile duct stones in choledocholithiasis had sensitivity and specificity rates of 41.4% and 92.7% for ultrasound, 72.7% and 83.3% for CT, and 86.7% and 60.9% for MRI, respectively. A total of 89 (69.5%) patients achieved complete bile duct clearance after blind laparoscopic choledocholithoextraction: 86 (81.1%) had choledochotomy, and 3 (13.6%)underwent transcystic common bile duct exploration. Choledochoscopy was required for laparoscopic choledocholithoextraction in 18.9% of choledochotomy patients and in 86.4% of those who underwent transcystic common bile duct exploration. Choledochoscopy demonstrated an overall bile duct stone clearance rate of 97.6%.

Common bile duct diameter reference values in patients with gallstone disease across various age-gender groups

Objective. Our goal was to establish common bile duct (CBD) diameter reference levels for abdominal ultrasound and percutaneous transhepatic cholecysto-cholangiography (PTCC) measurements with relevance to age and gender across the cohort of patients with underlying gallbladder disease excluding any intra- or extrahepatic bile ducts lesions.Materials and methods. 251 symptomatic patients with gallbladder disease and no signs of choledocholithiasis or biliary obstruction presenting to Liver and Pancreas Surgery Department, Sklifosovsky Research Institute for Emergency Medicine from January 2019 to June 2023 were reviewed. All the selected subjects underwent transabdominal ultrasound examination of hepato-biliary zone and PTCC. Common bile duct diameter, if not obscured, was measured at its widest visible portion by means of electronic calipers. The relationship between CBD size, age and gender was examined by nonparametric tests across stratified groups.Results. Mean sonographic CBD diameter was as high as 4.99 ± 1.17 mm with no evidence of correlation with age or gender. Mean cholecysto-cholangiography CBD diameter made up 6.49 ± 1.52 mm and reflected a considerable increase with age only: patients under 60 had CBD diameter significantly narrower, then those over 60. Basing upon the 95-percentile, we derived upper reference limit of 6.0 mm for US measurements without age and sex association, and for PTCC measurements regarding distinct age groups (8.0 mm in subjects < 60 years and 9.0 mm in subjects ≥ 60 years). Diameter of common bile duct was substantially higher on cholangiograms versus sonograms.Conclusion. Present study displayed notable common bile duct diameter discrepancies not only between ultrasound and cholangiography measurements, but also throughout age-dependent groups on cholangiograms. We imply those variations to be taken in consideration in case of contrasting various radiological evaluations of common bile duct, and in case of ruling out the diagnosis of choledocholithiasis or bile flow abnormality.

The role of magnetic resonance cholangiopancreatography in evaluation of etiological spectrum of obstructive jaundice

Jaundice is a commonly encountered problem in society. Discrimination between obstructive and non-obstructive causes is important to imply surgical intervention in cases of obstructive jaundice whereas medical management in non-obstructive jaundice. Nowadays diagnostic endoscopic retrograde cholangiopancreatography (ERCP) may be replaced by Magnetic resonance cholangiopancreatography (MRCP) as it has high level of resolution and reliability. We studied the role of MRCP in obstructive jaundice to evaluate its etiological spectrums and radiological findings. To evaluate the role of MRCP in the determination of aetiologies in obstructive jaundice, to assess degree and level of biliary obstruction and to correlate MRCP findings with post surgical follow-ups / ERCP/ histopathology. Total sixty-eight patients with a clinical diagnosis of obstructive jaundice referred for MRCP were included in our study. We correlated MRCP findings with the final diagnosis made by post-surgical follow-up / ERCP/ histopathology as a gold standard. For benign lesions, overall sensitivity of MRCP was 97.73%, specificity was 95.83% with an accuracy of 97.06%. MRCP had 94.74% sensitivity, 93.88% specificity, 94.12% accuracy in the diagnosis of choledocholithiasis, and 66.67% sensitivity, 98.39% specificity, and 95.59% accuracy in the diagnosis of benign strictures. For malignant lesions, accuracy, sensitivity, and specificity of MRCP were 97.06%, 95.83%, and 97.73%. MRCP is a highly reliable, accurate, non-invasive imaging technique and has a high sensitivity for the evaluation of aetiologies of obstructive jaundice.

Clinical Utility of Definitive Diagnostic Tests for Choledocholithiasis in Pediatric Patients with Mild Gallstone Pancreatitis

BackgroundGallstone pancreatitis was historically considered a risk factor for choledocholithiasis (CD). However, recent studies of adult patients evidenced a weak association between gallstone pancreatitis and CD. The aim of this study was to analyze this association in pediatric patients. MethodsWe conducted a retrospective study on patients with mild gallstone pancreatitis who underwent any definitive testing for CD (MRCP, ERCP, IOC), managed between March 2010 and September 2022. Patients were classified according to the presence or absence of risk factors for CD (total bilirubin ≥2 mg/dl; common bile duct >6 mm on ultrasound; and/or CD on ultrasound). We evaluated the diagnosis of CD on definitive testing in both groups and analyzed the predictive capacity of the presence of risk factors. ResultsEighty-four patients were included in the final analysis. Seventy-nine percent were females. The median age was 13 (4–17) years. Forty-seven (55.9%) patients had one or more risk factors. The definitive testing confirmed 13 (15.5%) cases of CD, 12 (25.5%) in the group of patients with risk factors and 1 (2.7%) in those without risk factors. The sensitivity, specificity, positive predictive value and negative predictive value of the presence of associated risk factors were 92.3, 50.7, 25.5 and 97.3%, respectively. ConclusionPediatric patients with gallstone pancreatitis without associated risk factors have a very low incidence of CD. In these patients we suggest performing a laparoscopic cholecystectomy without intraoperative cholangiography or any other definitive test for CD. Level of EvidenceLevel II, retrospective study.

Intermediate risk of choledocholithiasis: are we on the right path?

A retrospective observational study with a prospective database was conducted. The analysis included sociodemographic data, laboratory values, and imaging. Bivariate, multivariate, and receiver operating characteristic analysis were performed. Three hundred twenty-seven patients had an intermediate risk for choledocholithiasis. Half the patients were at least 65 years old. 24.77% were diagnosed with choledocholithiasis. Bile duct dilation was documented in only 3.06% of cases. Diagnosis of choledocholithiasis is associated with an age odds ratio (OR): 1.87 (P 0.02), alkaline phosphatase OR: 2.44 (P 0.02), and bile duct dilation greater than 6mm OR: 14.65 (P 0.00). High variability in the accuracy of imaging techniques results in a large number of patients classified as intermediate risk without choledocholithiasis in cholangioresonance. Therefore, enhancing the criteria to define intermediate risk for patients in order to optimize resources is of paramount importance.

Pyogenic liver abscess following endoscopic retrograde cholangiopancreatography procedure for choledocholithiasis

Pyogenic liver abscess (PLA) is a condition in which there is pus accumulation in the liver. It usually develops in the context of portal pyemia, through hematogenous seeding as well as via biliary disease. PLA is a rare, but important complication following biliary instrumentation such as endoscopic retrograde cholangiopancreatography (ERCP). We report a case of a 44-year-old man who initially presented with clinical features of ascending cholangitis. Laboratory investigations revealed leukocytosis as well as hyperbilirubinemia. Diagnosis of choledocholithiasis was then confirmed with an ultrasound examination, showing a 1×1 cm stone in the common bile duct. ERCP was performed and achieved stone clearance. However, the patient returned 1 month later with similar symptoms of right upper quadrant pain, fever and jaundice. Suspecting recurrent choledocholithiasis, an emergency ERCP was performed and showed pooling of radio-opaque contrast in the extra-biliary space. There were also multiple CBD stones seen. An urgent CT Abdomen was done and revealed multiple liver abscesses in bilateral liver lobes, with the largest measuring 4.5x5.9x2.1cm. The patient was treated conservatively with Augmentin and repeat ultrasound at 4 weeks interval showed no residual liver abscess.

Dynamic changes in liver function tests do not correctly reclassify patients at risk of choledocholithiasis beyond ASGE 2019 criteria.

Dynamic changes in liver function tests have been proposed to correctly reclassify the risk of choledocholithiasis; however, information is scarce and insufficient to recommend its use. Retrospective cohort of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) due to moderate and high risk of choledocholithiasis according to the 2019 American Society of Gastrointestinal Endoscopy (ASGE) guidelines. We evaluated whether significant changes in liver function tests (bilirubin, transaminases, or alkaline phosphatase), defined as an increase or a reduction ⩾30 or ⩾50% between two measurements taken with a difference of 24-72 h can correctly reclassify the risk of choledocholithiasis beyond the ASGE guidelines. The net reclassification index (NRI) was calculated for patients with and without choledocholithiasis. Among 1175 patients who underwent ERCP, 170 patients were included in the analysis (59.4% women, median 59.5 years). Among patients without a diagnosis of choledocholithiasis, the number of patients correctly reclassified by transaminases was slightly higher than those incorrectly reclassified (NRI = 0.24 for aspartate amino transaminase and 0.20 for alanine amino transaminase). However, among patients with a diagnosis of choledocholithiasis, it led to incorrect reclassification in a greater number of cases (NRI = -0.21 and -0.14, respectively). The benefits of reclassification were minimal for bilirubin and alkaline phosphatase, or for value changes >50%. A subgroup analysis showed similar findings in patients without a history of cholecystectomy and in those with normal bile duct. Dynamic changes in liver function tests do not improve choledocholithiasis risk classification beyond the 2019 ASGE criteria. New criteria should continue to be sought to optimize risk stratification.

Comparison of the Diagnostic Value of MRCP, CT, and Ultrasonography in Choledochal Stones with the Results of ERCP: Evidence from 1152 Case

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography (MRCP), computed tomography (CT), and ultrasonography (US) are widely used in the diagnosis of choledochal stones. This study aims to determine the sensitivity and diagnostic contribution of US, CT, and MRCP in detecting common bile duct stones and to compare them with ERCP. Materials and Methods: The study included 1152 patients who underwent ERCP diagnosed with choledochal stones. Initially, each patient underwent USG, CT, and MRCP. ERCP was performed 2-7 days later. The results were compared with the ERCP results. Sensitivity, specificity, positive predictive value (PPV), Negative Predictive Value (NPV), and F1 score were calculated. Results: Compared to ERCP, the most effective method in the diagnosis of choledocholithiasis is MRCP (F score: 0.84), CT (F score: 0.73), MR+BT (F score: 0.75), MR+BT+USG (F score: 0.55), and US (F score: 0.43). Conclusions: ERCP is the gold standard in treating stones in the common bile duct. However, since this method is invasive, its use for diagnostic purposes has decreased due to the possibility of complications. In diagnosing common choledochal stones, MRCP alone is sufficient regardless of other imaging methods.

EFFICACY OF NAVIGATOR-TRIGGERED PACE TECHNIQUE MRCP IN CHOLEDOCHOLITHIASIS

Aim: The navigator-triggered Prospective Acquisition Correction Enhancement technique is a method used to eliminate respiratory motion artifacts caused in magnetic resonance cholangiopancreatography examinations. The purpose of this study was to compare the diagnostic accuracy of navigator-triggered Prospective Acquisition Correction Enhancement tecnique magnetic resonance cholangiopancreatography examination with endoscopic retrograde cholangiopancreatography as a gold standard reference in presence of choledocholithiasis. 
 Materıal and Method: The diagnostic rates of magnetic resonance cholangiopancreatography examination performed with Prospective Acquisition Correction Enhancement technique in the diagnosis of choledocholithiasis were compared according to the results of the endoscopic retrograde cholangiopancreatography examination, which was accepted as a gold standard reference. 
 Results: Among 107 patients included in the study, 40 patients with magnetic resonance cholangiopancreatography and 36 patients with endoscopic retrograde cholangiopancreatography were diagnosed with choledocholithiasis. endoscopic retrograde cholangiopancreatography showed the presence of choledocholithiasis in 36 patients among 40 patients diagnosed as choledocholithiasis with magnetic resonance cholangiopancreatography. The positive predictivity value of the magnetic resonance cholangiopancreatography examination performed with the Prospective Acquisition Correction Enhancement technique was 90%, the negative predictivity value was 98.5%, the sensitivity was 97.3%, the specificity was 94.3%, and the diagnostic accuracy was 95.3%. 
 Conclusıon: We think that navigator-triggered magnetic resonance cholangiopancreatography examination obtained with Prospective Acquisition Correction Enhancement technique is a reliable method with high accuracy in the diagnosis of choledocholithiasis.

Pancreaticoduodenal and choledochal hemangiomatosis with vascular variation in a child: a rare disease with challenge starts from diagnosis—a case report

BackgroundVisceral hemangiomatosis is a benign tumor (rarer than hemangioma) that has not been reported to occur in the pancreas, duodenum, or choledoch. It can be easily confused with other pancreatic tumors or choledocholithiasis. Herein, we describe a case of a child with pancreaticoduodenal and choledochal hemangiomatosis and the key characteristics for the accurate diagnosis of pancreatic tumors based on previous reports and our findings.Case presentationWe report a case of a 2-year and 9-month-old child who presented with repeated and fluctuating jaundice for 3 months with a history of endoscopic stone removal in a local hospital, following the diagnosis of choledocholithiasis. An abdominal computed tomography revealed a previously undiagnosed pancreatic head tumor and celio-mesenteric trunk (a rare vascular variation). This was misdiagnosed as a pancreatic neuroendocrine tumor. Since the patient’s parents refused FNA biopsy and insisted on surgery, pancreaticoduodenectomy was performed; however, postoperatively, the child was correctly diagnosed with pancreaticoduodenal and choledochal hemangiomatosis. Although the patient was in good condition and had gained 4 kg in weight 3 months postoperatively, pancreaticoduodenectomy could have been avoided if an accurate diagnosis had been established before or during the operation.ConclusionOur report highlights the difficulty in diagnosing visceral hemangiomatosis. Radiologists, endoscopists, and surgeons should consider this possibility in cases of repeated and fluctuating jaundice that cannot be explained by choledocholithiasis alone.

Contribution of Endoscopic Ultrasound (EUS) in Biliopancreatic Pathology: Experience of the Hepato Gastroenterology Moroccan Department

Introduction: Endoscopic ultrasound (EUS) is a method of exploration in gastroenterology, it combines ultrasound and endoscopy for the examination of the digestive tract and nearby structures. It is an ultrasound technique that allows the use of high-definition ultrasound transducers. Materials and methods: It is a descriptive retrospective study covering a period of 34 months, from 01/2019 to 10/2021. It concerned 100 patients who had endoscopic ultrasound for biliopancreatic pathology, in the and the university hospital Sheikh Khalifa. We noted the demographic, clinical and morphological data, such as transcutaneous ultrasound, abdominal CT scan and MRI as well as the EUS. The results of the EUS were compared with the imaging and histology data when performed. We were therefore able to evaluate the reliability of each examination and thus its strong and weak points. Results: The average age of our patients was 58 years, with a sex ratio: 1.05. The symptomatology was dominated by abdominal pain and jaundice, the biology by cytolysis and biological cholestasis syndrome. We noted a predominance of tumor pathology with 42% followed by inflammatory pathology: acute pancreatitis as part of the etiological assessment. The reliability of EUS in the diagnosis of pancreatic cancer is 88% with a reliability of abdominal CT of 68%. Our study also allowed us to evaluate with precision the reliability of detection of lymph node and vascular invasion of biliopancreatic cancers, which was 88%. We also noted other pathologies for which EUS was a good diagnostic tool, main bile duct stones but also cystic lesions of the pancreas. Conclusion: In view of the comparative study of these results with the other types of explorations, of which the EUS, proved to be more effective in the exploration of the pancreatic region especially in for the assessment of tumor extension and diagnosis of choledocholithiasis and characterization of cystic lesions. The EUS has a therapeutic interest ....

Ascending Cholangitis Secondary to Choledocholithiasis In Post Cholecystectomy Patient: A Diagnostic Dilemma

Choledocholithiasis is the presence of stones in the common bile duct (CBD). Choledocholithiasis in post-cholecystectomy is rare. Nonetheless, this is a report of a 40-year-old woman who was presented with severe epigastric pain with high-grade fever, tea-coloured urine, pale stool, and jaundice. She had a history of pangastritis and had cholecystectomy two years ago.This case report describes the significant diagnostic dilemma of the choledocholithiasis, particularly in a post-cholecystectomy patient who had pangastritis and was presented with severe epigastric pain. The diagnosis of choledocholithiasis was missed as the early symptoms of choledocholithiasis are similar to those of pangastritis. Therefore, treatment for choledocholithiasis was delayed. A high index of suspicion for diagnosis of choledocholithiasis must be emphasized among primary care practitioners even in a post-cholecystectomy patient. This will enable early treatment for the patient and prevent complications such as ascending cholangitis and sepsis. Bangladesh Journal of Medical Science Vol. 21 No. 02 April’22 Page : 458-462

Diagnostic accuracy of ultrasonography compared with magnetic resonance cholangiopancreatography in the detection of choledocholithiasis.

The aim of this study is to compare the diagnostic accuracy of ultrasonography (US) with magnetic resonance cholangiopancreatography (MRCP) in the diagnosis of choledocholithiasis in context of laboratory blood test values. This retrospective study included patients who underwent both MRCP and US as part of their choledocholithiasis workup. MRCP findings, reviewed by two board-certified radiologists, laboratory findings, and US reports were collected. Our study included 243 patients. On US examination 74 cases were found dilated (30.5%), while 94 cases showed dilation (38.7%) by MRCP. The overall accuracy of US was 76.1%, where 185 patients had similar MRCP and US findings, 7.8% had false positive ultrasound, and 16% had false negative ultrasound finding. The accuracy of ultrasound was significantly higher in males (p= .013). In addition, a significant difference in duct dilatation as found by ultrasound and accuracy of diagnosis (p= .01). Although US has a relatively low accuracy, its properties of being cost-effective and non-invasive make it an ideal first step in the diagnosis of choledocholithiasis. If a patient has elevated liver enzymes or a high risk of choledocholithiasis, we recommend that MRCP be performed even no dilation was seen on US.

Role of endosonography in the diagnosis of choledocholithiasis: emergency hospital experience

Role of endosonography in the diagnosis of choledocholithiasis: emergency hospital experience

Validación de los criterios predictivos de alto riesgo para coledocolitiasis de la Sociedad Americana de Endoscopia Gastrointestinal, 2010: Experiencia de un centro del caribe colombiano

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) has become the gold standard for diagnosis and treatment of choledocholithiasis. The American Society for Gastrointestinal Endoscopy (ASGE) in 2010 proposed stratifying patients into 3 risk levels; however, studies have found controversial results about the predictive parameters of these diagnostic criteria. The objective of this study is to determine the performance of the high-risk predictive criteria of the ASGE 2010 in the diagnosis of choledocholithiasis in a Colombian Caribbean population. Methods: Retrospective cross-sectional study, which included patients with suspected choledocholithiasis, and who were taken for evaluation by ERCP, meeting the criteria proposed by the ASGE of high probability. The result obtained was compared with the presence of choledocholithiasis on ERCP, from which values and 95% confidence intervals were estimated for sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratio. Results: A total of 118 patient data were included in this study. The median age of the patients was 46 years (IQR= 31; 17- 89); 78% (n= 92) were female. 65.3% (n= 77) were older than 55 years. The ERCP result was positive in 81.4% (n= 96) of the patients. The presence of an altered liver profile (90%) was found to be the most sensitive test, clinical cholangitis (86%) the most specific, the presence of duct lithiasis by US (85%) was the test with the highest positive predictive value, and the presence of duct lithiasis by US (35%) was the test with the highest negative predictive value. Conclusions: The predictive parameters of the ASGE 2010 criteria for the diagnosis of choledocholithiasis show variability with respect to the performance proposed in the guidelines.

Routine laparoscopic management of common bile duct stones

Background: The prevalence of common bile duct stones associated with cholelithiasis increases with age and is about 15 % in the 8th decade of life but its management is still controversial. Some surgeons prefer the single-stage approach with laparoscopy while others suggest the two-stage management with preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy. Objective: The aim of the present study was to evaluate the efficacy of feasibility of single-stage laparoscopic surgery in patients with cholelithiasis and choledocholithiasis. Material and methods: We conducted a retrospective study with prospectively collected data between July 2008 and July 2018. Results: Of 2447 laparoscopic cholecystectomies performed during the study period, 416 presented common bile duct stones. The global success of the transcystic approach to clear common bile duct stones was 81.2%, 70.4% in the cases with preoperative diagnosis of choledocholithiasis and 92.9% for other diagnoses. The rate of complications was 4% without deaths or bile duct injuries. Conclusion: Single-stage laparoscopic surgery is an efficient and safe approach based on the high global success of transcystic exploration. The preoperative diagnosis of choledocholithiasis reduces the efficacy of the procedure due to greater indication of choledocotomy, with complications and longer length of hospital stay.

Predicting the Diagnosis of Choledocholithiasis in Elderly Patients by Assessing Hepatic Functions

Predicting the Diagnosis of Choledocholithiasis in Elderly Patients by Assessing Hepatic Functions

Intraoperative cholangiography: Learning curve in a General Surgery residency

Background: The use of dynamic intra-operative cholangiography (dIOC) during laparoscopic cholecystectomy (Lap Chole) remains a topic under discussion. Objectives: This study aims to describe and evaluate the learning curve and findings in the dIOC during laparoscopic cholecystectomies performed by Residents of General Surgery, including it as a tool for a safe cholecystectomy, as well as training for the development of skills and abilities. Material and methods: Patients with indication of scheduled or emergency laparoscopic cholecystectomy were included. In the surgeries, traction was performed according to Hunter, critical safety vision and systematic dIOC, by a senior Resident and the dIOC by a less trained resident, tutored by a staff surgeon. Learning curve, operative times, dIOC time relationship with Lap Chole duration time (IOC/LC), repeated cystic dissection, cystic lithiasis and choledocholithiasis were evaluated. Results: 456 patients were operated for one year (2017-2018). It was observed that regardless of who performs the dIOC, they were able to improve their learning curve, objectifying shorter times for Lap Chole, dIOC and the IOC/LC relationship. The learning coefficients were better in complex surgeries in relation to the semester. 5.26 % had choledocholithiasis (n = 24), of these, 66.7% had cystic lithiasis (n = 16) and 25% associated cholecystitis (n = 6). All were resolved trancystically. There were no conversions and dIOC was performed in 100% of cases. Conclusion: The dIOC is an ideal procedure to be practiced systematically during residency. Because it gives the necessary training for the management of the transcystic pathway, allows avoiding an upper bile duct injury and the diagnosis of choledocholithiasis.

Comparison of pre-operative ultrasonography and magnetic resonance cholangiopancreatography with intra-operative surgical findings among patients suspicious to choledocholithiasis

Background: Choledocholithiasis with cholelithiasis is a common problem in the middle and older age group people. Aim of this study is to assess the usefulness of ultrasonography in the diagnosis of choledocholithiasis in resource poor set up.Methods: After matching the inclusion and exclusion criteria, all cases of diagnosed choledocholithiasis were taken for this prospective, single center, observational study.Results: Out of total 130 subjects, 41 were male and 89 were female. Increased incidence of choledocholithiasis was found in females (M:F=1:2.08). The mean age of presentation was 49.27±10.60 years. Ultrasonography was able to diagnose common bile duct (CBD) stones in 57 patients (43.84%) and ductal dilatation in 89 (68.46%). Whereas, magnetic resonance cholangiopancreatography (MRCP) detected CBD stones in 112 (86.15%). Cholelithiasis was associated with choledocholithiasis in 108 patients (83.07%).Conclusions: In the evaluation of choledocholithiasis, in our study particularly trans-abdominal ultrasonography (USG) seemed to have a lower yield than expected for accuracy in determining choledocholithiasis when compared to MRCP and Intra-operative findings. So, a negative USG in a particular may not exclude choledocholithiasis. So, MRCP is the ‘investigation of choice’ among the suspicious patients for CBD stone disease. That is why prior to cholecystectomy in symptomatic patients with deranged liver function test, MRCP always to be done, to detect the missed stone in CBD.