Evidence Of Common Bile Duct Stones Research Articles

Curative surgical treatment of common bile duct stones: Retrospective cohort study.

In the event of symptomatic common bile duct (CBD) stones with dilated CBD, one possible curative treatment option is stone extraction through choledocotomy associated with cholecystectomy. Endoscopic treatment is only reserved for residual stones at 6weeks. The aim of this study was to evaluate the results from laparoscopic curative surgical treatment of CBD stones with dilated CBD. This is a retrospective single-centered cohort study. All consecutive patients admitted for laparoscopic cholecystectomy with evidence of CBD stones with dilated CBD from January 2010 to December 2020 at our center were included. Success was defined by CBD clearance at 6weeks. Need for additional procedures, such as endoscopic sphincterotomy, immediate, and end-of-procedure morbi-mortality as well as factors associated with procedure failure, were also studied. A total of 246 patients who received curative treatment were included in the study. The success rate for the curative treatment was 93.1% (229 patients). Immediate postoperative morbidity was 24.4% with a 5.3% reintervention rate. Immediate and 6-week postoperative mortality rates were zero and 0.4%, respectively. The mean length of stay was 11.3days. Factors associated with procedure failure appeared to be the occurrence of an early postoperative complication and the need for readmission during the period between surgery and drain removal. This study indicates that laparoscopic curative surgical treatment for symptomatic CBD stones may be performed with acceptable results without routine need for additional procedures.

Routine intraoperative cholangiography during laparoscopic cholecystectomy: application of the 2016 WSES guidelines for predicting choledocholithiasis

BackgroundRoutine use of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) for detecting common bile duct stones remains controversial. The 2016 World Society of Emergency Surgery (WSES) guidelines on acute calculous cholecystitis proposed a risk stratification for choledocholithiasis. Our present study aimed to (1) examine the findings of common bile duct (CBD) stones in patients underwent LC with routine use of IOC, and (2) validate the 2016 WSES risk classes for predicting choledocholithiasis.MethodsAll patients had LC with IOC routinely performed from November 2012 to December 2017 were reviewed retrospectively. Patients were classified into high-, intermediate-, and low-risk groups based on the 2016 WSES risk classes with modification.ResultsA total of 990 patients with LC and routine IOC were enrolled. CBD stones were detected in 197 (19.9%) patients. The rate of CBD stone detected in low-, intermediate-, high-risk groups were 0%, 14.2%, and 89.6%, respectively. Predictors as following: evidence of CBD stones on abdominal ultrasound or computed tomography, CBD diameter > 6 mm, total bilirubin > 4 mg/dL, bilirubin level = 1.8–4 mg/dL, abnormal liver biochemical test result other than bilirubin, presence of clinical gallstone pancreatitis had statistical significance between patients with and without CBD stones. Major bile duct injury was found in 4 patients (0.4%). All 4 patients had uneventful recovery after repair surgery.ConclusionsBased on our study results, the 2016 WSES risk classes for choledocholithiasis could be an effective approach for predicting the risk of choledocholithiasis. Considering its advantages for detecting CBD stones and biliary injuries, the routine use of IOC is still suggested.

Post Endoscopic Retrograde Cholangiopancrea-Togram (ERCP) Perforation Managed Successfully Conservatively: A Case Report

Introduction: We aim to report an uncommon case of post ERCP perforation that effectively managed conservatively in non-hepatobiliary surgery centre. Case report: A 46-year-old man diagnosed to have obstructive jaundice secondary to distal common bile duct (CBD) stone. He underwent ERCP at a private centre, sphincterotomy was performed, but, the operator had failed to insert the stent and complicated with post ERCP perforation evidenced by contrast extravasation beyond 1/3rd of the CBD and referred to our centre. Patient was subjected for re ERCP. There were difficulties in cannulating the CBD and stent was inserted. Cholangiogram revealed contrast leak around the pancreatic duct and bifurcation of hepatic duct. There was no evidence of CBD stone. Computed Tomography (CT) of the abdomen revealed extensive subcutaneous emphysema on the right side of the abdomen to right inguinal region, extensive retroperitoneal free air and pneumoperitoneum, but there were no free fluid or contrast extravasation. The patient subjected for non-operative management (NOM) for the complication and kept fasting with total parenteral nutrition and intravenous antibiotic. He recovered well with the opted management. Patient was programmed with Gastrograffin study after 10 days that showed no evidence of contrast leak to suggest free bowel injury. He was allowed orally after that and was discharged well after 15 days with stent in situ. During follow up, he was well, and the stent removed after 3 months. Patient planned for laparoscopic cholecystectomy and on table cholangiogram. Conclusion: Post ERCP perforation is uncommon but lethal. Early recognition of the complication is crucial hence appropriate management can be arranged to avoid death. To date, surgery is not the only choice available to manage this complication.

1376 Pseudoaneurysm of the Cystic Artery: An Unusual Case of Hemobilia in a Teenage Patient

INTRODUCTION: Pseudoaneurysm of the cystic artery is a rare cause of hemobilia and often derives from the inflammatory changes in cholecystitis. Knowledge regarding this topic is limited with rare occurrence reported in the literature. This may be the first reported case of a cystic artery pseudoaneurysm causing biliary obstruction in a pediatric patient. This case emphasizes the importance of considering hemobilia whenever gastrointestinal bleeding is associated with cholestatic liver injury as well as including cystic artery aneurysm in the differential diagnosis of hemobilia. CASE DESCRIPTION/METHODS: A 16-year-old obese male scheduled for elective cholecystectomy for symptomatic cholelithiasis was admitted for worsening abdominal pain associated with nausea and vomiting. After admission, patient remained afebrile with resolving symptoms, but rising cholestatic markers. MRCP showed Common Bile Duct (CBD) dilation to 1 cm but without CBD stones. EUS was performed to evaluate for choledocholithiasis but was limited by the unexpected finding of fresh blood in the duodenum. CBD dilation to 8 mm was seen but was without evidence of CBD stones. Cholestatic injury worsened, prompting ERCP as distal CBD stones were still the leading concern. Upon examination prior to cannulation, passage of blood and blood clots was seen from the native ampulla. Cholangiogram showed multiple filling defects within the CBD suggestive of blood clots, sphincterotomy was performed and multiple sweeps with the balloon catheter removed only blood clots with no stones seen. CT angiography was performed and found a focal arterial density collection in the posteromedial gallbladder wall, most likely due to a pseudoaneurysm of the cystic artery. Interventional Radiology performed coil embolization of the cystic artery prior to cholecystectomy. Laparoscopic cholecystectomy was converted to open laparotomy after the discovery of extensive pericholecystic adhesions to the gallbladder as well as a cholecystocolonic fistula. The fistula was repaired and the gallbladder was removed with ligation of the cystic artery just distal to the coils. Symptoms resolved and the patient's laboratory values normalized. DISCUSSION: A rare case of cholestatic liver injury and hemobilia secondary to cystic artery pseudoaneurysm in a pediatric patient is reported. As demonstrated in this report, immediate angiography and embolization of the involved artery followed by cholecystectomy may be the optimal treatment regardless of patient age.

Linear echoendoscope-guided ERCP for the diagnosis of occult common bile duct stones

BackgroundLess than 67% of patients with intermediate risk for common bile duct (CBD) stones require therapeutic intervention. It is important to have an accurate, safe, and reliable method for the definitive diagnosis of CBD stones before initiating therapeutic endoscopic retrograde cholangiopancreatography (ERCP). Few publications detail the diagnostic efficacy of linear echoendoscopy (EUS) for CBD stones.Methods30 patients with biliary colic, pancreatitis, unexplained derangement of liver function tests, and/or dilated CBD without an identifiable cause were enrolled in the study. When a CBD stone was disclosed by linear EUS, ERCP with stone extraction was performed. Patients who failed ERCP were referred for surgical intervention. If no stone was found by EUS, ERCP would not be performed and patients were followed-up for possible biliary symptoms for up to three months.ResultsThe major reason for enrollment was acute pancreatitis. The mean predicted risk for CBD stones was 47% (28–61). Of the 12 patients who were positive for CBD stones by EUS, nine had successful ERCP, one failed ERCP (later treated successfully by surgical intervention) and two were false-positive cases. No procedure-related adverse events were noted. For those 18 patients without evidence of CBD stones by EUS, no false-negative case was noted during the three-month follow-up period. Linear EUS had sensitivity, specificity, positive and negative predicted values for the detection of CBD stones of 1, 0.9, 0.8 and 1, respectively.ConclusionLinear EUS is safe and efficacious for the diagnosis of occult CBD stones in patients with intermediate risk for the disease.

Is Endoscopic Ultrasound Needed as an Add-on Test for Gallstone Diseases Without Choledocholithiasis on Multidetector Computed Tomography?

Choledocholithiasis commonly occurs in patients with symptomatic cholelithiasis. Although the recently developed multidetector computed tomography (MDCT) scan enhances the ability to diagnose choledocholithiasis, this technique is considered to have some limitations for evaluating the common bile duct (CBD). The purpose of this study was to evaluate the necessity for performing endoscopic ultrasound (EUS) as an add-on test to detect choledocholithiasis in patients who were diagnosed with gallstone disease without choledocholithiasis based on MDCT. Three hundred twenty patients with gallstone disease and no evidence of CBD stones according to MDCT underwent EUS between March 2006 and April 2011. If CBD stones were suspected based on the EUS results or clinical symptoms, a final diagnosis was obtained by endoscopic retrograde cholangiopancreatography (ERCP). The patients' medical records were retrospectively analyzed based on clinical symptoms, biochemical findings, and results of the imaging studies. CBD stones were not detected with MDCT in 41 (12.8 %) out of 320 patients with gallstone disease. The causes for these discrepancies could be attributed to small stone size (n = 19, 46.3 %), isodensity (n = 18, 43.9 %), impacted stones (n = 1, 2.4 %), and misdiagnosis (n = 3, 7.3 %). If EUS were used as a triage tool, unnecessary diagnostic ERCP and its complications could be avoided for 245 (76.6 %) patients. MDCT may not be a primary technique for detecting CBD stones. EUS should be performed instead as an add-on test to evaluate the CBD for patients with gallstone-related disease. In particular, EUS should be routinely recommended for patients with abnormal liver enzyme levels, pancreatitis, and dilated CBD.

Acute transient hepatocellular injury in cholelithiasis and cholecystitis without evidence of choledocholithiasis

To investigate acute transient hepatocellular injury in patients with cholelithiasis and cholecystitis but no evidence of choledocholithiasis. The medical records of patients with cholelithiasis who underwent cholecystectomy between July 2003 and June 2007 were retrospectively reviewed. Imaging studies to detect common bile duct (CBD) stones were performed in 186 patients, who constituted the study population. Biochemical liver tests before and after surgery, and with the presence or absence of CBD stones were analyzed. In 96 patients with cholelithiasis and cholecystitis without evidence of CBD stones, 49 (51.0%) had an alanine aminotransferase level elevated to 2-3 times the upper limit of normal, and 40 (41.2%) had an elevated aspartate aminotransferase level. Similar manifestations of hepatocellular injury were, as would be expected, even more obvious in the 90 patients with CBD stones. These markers of hepatocellular injury resolved almost completely within 2 wk to 1 mo after cholecystectomy. Compared to 59 patients with histologically less severe cholecystitis in the group undergoing urgent surgery (total 74 patients), the 15 patients with a gangrenous gallbladder had a higher mean level of total bilirubin (1.14 +/- 1.27 mg/dL vs 2.66 +/- 1.97 mg/dL, P < 0.001) and white cell count (9480 +/- 4681/microL vs 12840 +/- 5273/microL, P = 0.018). Acute hepatocellular injury in cholelithiasis and cholecystitis without choledocholithiasis is mild and transient. Hyperbilirubinemia and leukocytosis may predict severe inflammatory changes in the gallbladder.

Improving the safety of laparoscopic cholecystectomy: the routine use of preoperative magnetic resonance cholangiography

The aim of this study was to determine the value of routinely performed preoperative magnetic resonance cholangiography (MRC) in detecting common bile duct (CBD) stones in patients stated to undergo elective laparoscopic cholecystectomy. In addition, we used MRC to investigate possible variants of the cystic duct. Magnetic resonance cholangiography was performed preoperatively in 773 patients (311 male and 462 female; median age 55 years, range 16-91) who had no clinical signs of cholestasis prior to undergoing elective laparoscopic cholecystectomy. In cases where the MRC was positive for CBD stones, endoscopic retrograde cholangiopancreatiography (ERCP) was then performed. A total of 532 patients were available for continuous postoperatively follow-up (median 54 months, range 36-85). In 462 patients (247 female, and 215 male), MR images were also reviewed for variants of the cystic duct. In 705 patients (91%), MRC was negative for CBD stones. In 64 patients (9%) MRC was positive. Of these patients, 47 (6%) had CBD stones on ERCP. In 12 patients (2%), MRC was false positive. In five cases (0.6%), ERCP had an inconclusive result postoperative follow-up (532 patients, or 69%) revealed evidence of CBD stones in three patients (10.4%) despite a preoperative negative MRC result. Anatomical variants in the course of the cystic duct and its confluence with the common bile duct were found in 27 of 462 patients (6%). Magnetic resonance cholangiography proved to be a reliable screening technique in the preoperative evaluation of patients with silent CBD stones. Imaging of the course of the cystic duct is possible in a high percentage of cases. Therefore, MRC can be recommended as a screening technique before laparoscopic cholecystectomy.

EndoScope: world literature reviews

To remove the myth that intraoperative cholangiogram (IOC) is essential to avoid duct injuries during laparoscopic cholecystectomy (LC), a study was done at the University of Ottawa, Ontario, Canada, by John W. Lorimer and Robert J. Fairfield-Smith. In this study 525 patients underwent LC from March 1991 to September 1993 without IOC. There were no common bile duct (CBD) injuries during this study. The indications for LC were chronic cholecystitis (82.1%), acute cholecystitis (9.1%), gallstones pancreatitis (5.6%), and jaundice (3.2%). Gallstones were present in 98.3% of cases. The median operative time was 79.5 min. Twentyfive patients (4.8%) were converted to open cholecystectomy. The reasons for conversion were dense adhesions (20 cases), inadequate exposure of gallbladder due to obesity (three cases), small-bowel injury (one case), and cystic artery bleeding (one case). Based on clinical criteria of history of jaundice, acute pancreatitis, elevated liver enzymes, and ultrasound-proven or -suspicion of common duct stone, preoperative endoscopic retrograde cholangiography (ERC) was performed in 33 patients. Out of these 33 cases, 13 patients were diagnosed as having CBD calculi (diagnostic accuracy of 40%) and treated with endoscopic sphincterotomy (ES). In the postoperative period (up to 15 months after LC), ERC was done in 14 patients, and five patients required ES for removal of their CBD stones. It was believed that three other patients in the postoperative group has passed duct stones before ERC (episodic biliary pain and elevated liver enzymes). One patient with an asymptomatic duct stone refused a second attempt at ES. Thus the incidence of CBD stones (22 out of 525 cases) was 4.2% and the incidence of retained or missed stone (nine out of 525) was 1.66%. Out of 47 patients (9%) (33 pre-op and 14 postop) subjected to ERC/ES, four patients developed a complication. Duodenal perforation occurred in one patient and pancreatitis occurred in the other three. Out of 525 patients undergoing LC, 28 complications (one fatal) occurred in 25 patients with a morbidity of 4.8% and a mortality of 0.19%. Based on these data the authors recommend the selective use of preoperative ERC/ES based on clinical, biochemical, and ultrasound evidence of CBD stone. As well, they argue that routine IOC is unnecessary, citing a study in which IOC was routinely employed, yet ERC/ES was still required in 11% of patients as compared to 9% in this series, suggesting that IOC may not reduce the dependence on ERC/ES.

ROUTINE USE OF ULTRASOUND 24 HOURS BEFORE LAPAROSCOPIC CHOLECYSTECTOMY CAN PREDICT THE NEED FOR INTRAOPERATIVE CHOLANGIOGRAM: RESULTS OF A 12‐MONTH PROSPECTIVE AUDIT

SUMMARYIntraoperative cholangiograms and exploration of the common bile duct (CBD) during laparoscopic cholecystectomy are technically more demanding than during open cholecystectomy. This has led to many surgeons using a selective policy for cholangiography. In this study we prospectively assessed whether biliary ultrasound (CBD diameter ≥6 mm) or one or more abnormal liver function tests (LFTs) performed in the 24 hours preoperatively could predict the need for cholangiography. Forty‐five patients were studied (14 male, 31 female), mean age 47.8 years. All patients with one or both tests abnormal preoperatively (19 patients) underwent intraoperative cholangiograms. Seven CBD stones were identified (16%). There was no evidence of CBD stones in patients not undergoing cholangiography at a median follow‐up of 18 months. In patients with stones, three underwent open CBD exploration, and four underwent endoscopic retrograde choledochopancreatography (ERCP) and sphincterotomy in the early postoperative period without complications. CBD diameter ≥6 mm is a useful predictor of CBD stones. These may be treated successfully by postoperative ERCP.