Intraoperative ERCP Research Articles

Managing concomitant gallbladder stones and common bile duct stones in the laparoscopic era: A systematic review

There is still no consensus on the ideal management of common bile duct (CBD) stones. This article aims to review the management of concomitant gallbladder stones and CBD stones in the laparoscopic era. A PubMed database search was performed to identify MEDLINE articles from 1986 to 2010 using the key terms "common bile duct stones,""cholecystectomy,""bile duct exploration,""ERCP" (endoscopic retrograde cholangiography), and "endoscopic sphincterotomy." There were five randomized comparative trials (RCT) comparing sequential preoperative ERCP and laparoscopic cholecystectomy (LC) to laparoscopic common bile duct exploration (LCBDE). Two RCTs showed similar stone clearance rates and shorter hospital stays in the LCBDE group, while three RCTs showed similar stone clearance rates and hospital stays in sequential preoperative ERCP, LC and LCBDE groups. There were two RCTs comparing LCBDE to sequential LC and postoperative ERCP. One showed similar stone clearance rate and shorter hospital stay in LCBDE group, while the other showed similar stone clearance rate and hospital stay. There were three RCTs comparing sequential preoperative ERCP and LC against LC with intraoperative ERCP. All three studies showed similar stone clearance rates and shorter hospital stays in the intraoperative ERCP group. There was only one RCT comparing sequential preoperative ERCP and LC against sequential LC and postoperative ERCP. This showed a similar stone clearance rate and shorter hospital stay in the postoperative ERCP group. Different management approaches of concomitant gallbladder stones and CBD stones were equivalent in efficacy. However, one-stage management had the advantage of providing a shorter hospital stay.

Sp282: Peroral Transhepatic Cholangioscopy and Lithotripsy After Biliopancreatic Diversion

Bariatric surgery makes ERCP more difficult. Peroral ERCP is feasible using enteroscopy after Rox-en-Y, and intraoperative ERCP through the excluded gastric antrum. However, after BPD with distal gastrectomy patients with CBD stones require either repeat surgery or PTC, the former particularly inconvenient after cholecystectomy. We offer a novel endoscopic approach in this setting, illustrated by the case of a 72 y.o. female with symptomatic proven residual CBD stones after BPD.

Single-step treatment of gall bladder and bile duct stones: A combined endoscopic–laparoscopic technique

Introduction The advent of endoscopic techniques changed surgery in many regards. In the management of cholelithiasis; laparoscopic cholecystectomy (LC) is today the treatment of choice. This has created a dilemma in the management of choledocholithiasis. Today a number of options exist, including endoscopic sphincterotomy (ES) before LC in patients with suspected common bile duct (CBD) stones, laparoscopic common bile duct exploration (LCBDE) by the transcystic approach or laparoscopic choledocotomy, open CBD exploration and postoperative ERCP. A major concern regarding both pre- and postoperative extraction of CBD stones (CBDS) by the ERCP is the risk of development of pancreatitis, also more than 10% of the preoperative ERCP is normal. More recently the alternative technique of combined LC with intraoperative ERCP and ES is emerging in an attempt to manage cholecysto-choledocholithiasis in a single-step procedure. Objectives The aim of this work was to assess the treatment of common bile duct stones (CBDS) in a one-stage operation by laparoscopic cholecystectomy (LC) and intraoperative endoscopic retrograde cholangiopancreatography (LC + IO-ERCP) and endoscopic sphincterotomy (ES). Patients and methods This study was carried out on 45 patients with gall bladder stones and with suspected or confirmed CBDS at the Gastrointestinal Surgery Unit in the Main Alexandria University Hospital. They were treated by a single-step procedure combining LC and IO-ERCP. Laparoscopic intraoperative cholangiography (IOC) was carried out to confirm the presence of CBDS. A soft-tipped guide-wire was passed through the cystic duct and papilla into the duodenum. A papillotome was inserted endoscopically over the guide-wire. Endoscopic sphincterotomy was performed and the stones were extracted with a retrieval balloon or with a Dormia basket. The surgical operating time, surgical success rate, postoperative complications, retained CBDS, and postoperative length of hospital stay were assessed. Results There were 30 females and 15 males. Their mean age was 45.07 + 11.3 years (ranging from 27 to 65years). Twenty-seven patients had confirmed CBDS by preoperative ultrasound (US) and/or MRCP. Eighteen patients were suspected for CBDS on clinical, laboratory and/or US basis. Conversion to open cholecystectomy occurred in one case due to severe adhesions at the Calot's triangle. IOC revealed the presence of CBDS in 36 patients. IO-ERCP with ES was performed successfully in 33 patients and stones were extracted endoscopically. Passage of the guide-wire through the papilla failed in three patients. Cholecystectomy was completed laparoscopically in 44 patients. The mean operative time was 119 + 14.4 min (ranging from 100 to 150 min). Minor postoperative complications occurred in 15 patients. No postoperative complications related to the procedure, i.e., pancreatitis, bleeding, perforation, were encountered. Patients regained their bowel motion on the next day and were discharged after a mean hospital stay of 2.55 + 0.89 days. None of the patients presented on the postoperative follow-up with symptoms, signs, laboratory or radiological evidence of retained CBDS. The mean duration of the postoperative follow-up was 9 + 4.07 months (ranging from 3 to14 months). Conclusion The current study suggests that LC + IO-ERCP for the management of cholecysto-choledocholithiasis is a safe and aneffective technique with a low rate of post-ERCP pancreatitis. It offers another alternative for surgeons especially those who do not practice LCBDE to treat patients in a single setting. However, additional studies with larger patient populations are needed keeping in mind that the limiting characteristic is the proximity and availability of the endoscopic settings.

Intraoperative ERCP during laparoscopic cholecystectomy for patients with symptomatic cholecystolithiasis and suspected choledocholithiasis but failed preoperative ERCP

Intraoperative ERCP during laparoscopic cholecystectomy for patients with symptomatic cholecystolithiasis and suspected choledocholithiasis but failed preoperative ERCP

Intraoperative transgastric ERCP after a Roux-en-Y gastric bypass

Intraoperative transgastric ERCP after a Roux-en-Y gastric bypass

The long-term follow-up of patients with positive intraoperative cholangiograms during laparoscopic cholecystectomy

The routine use of laparoscopic common bile duct exploration (LCBDE) for common bile duct (CBD) stones discovered during cholecystectomy would be further supported if the long-term outcomes were similar to those for endoscopic retrograde cholangiopancreatography with endoscopic papillotomy (ERCP/EP). A retrospective review was completed of 151 patients who had a positive intraoperative cholangiogram (IOC) during laparoscopic cholecystectomy (LC). A "positive" IOC was defined as a filling defect or lack of contrast flow into the duodenum. A "successful" CBDE was defined as a negative IOC after completion of CBDE. Long-term follow-up was obtained using a standardized questionnaire to determine the incidence of recurrent biliary pain or need for subsequent ERCP/EP. CBD exploration was attempted in 142 patients (transcystic LCBDE 126 and open CBDE 16) and was successful in 107 of 142 (75%). Transcystic LCBDE was successful in 90 of 126 (71%). ERCP/EP was used in 41 patients; 35 of these cases were for failed LCBDE. Pancreatitis was not observed in any patient after CBDE but was observed in 3 of 41 patients (7.3%) after ERCP/EP. Long-term follow-up of the LCBDE versus ERCP/EP patients revealed no difference in the incidence of recurrent biliary pain or need for subsequent ERCP (mean follow-up time of 61 months). LCBDE is safe and effective in the majority of cases when an attempt at transcystic LCBDE was made. In addition, after long-term follow-up of >5 years, the outcomes were similar if the stones were removed by intraoperative laparoscopic methods versus postoperative ERCP. LCBDE seems worthy of pursuing when an intraoperative CBD stone is discovered.

Intraoperative ERCP for the Management of Choledocholithiasis: A Comparative Study

Intraoperative ERCP for the Management of Choledocholithiasis: A Comparative Study

Intraoperative Transjejunal ERCP: Case Reports

ERCP may be difficult to perform in the subset of patients with surgically altered anatomy of the upper GI tract. In expert hands, ERCP usually can be completed in patients who have undergone gastrectomy with a Billroth II anastomosis and is often successful after pancreaticoduodenectomy (Whipple operation). 1 Feitoza AB Baron TH Endoscopy and ERCP in the setting of previous upper GI tract surgery. Part II: postsurgical anatomy with alteration of the pancreaticobiliary tree. Gastrointest Endosc. 2002; 55: 75-79 Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar However, other surgical reconstructions, such as a gastrectomy or gastric bypass with Roux-en-Y hepaticojejunostomy may render endoscopic access to the biliary and pancreatic ductal orifices difficult if not impossible. MRCP will often provide sufficient visualization of ductal anatomy in such cases, and percutaneous transhepatic cholangiography (PTC) provides alternative access to the bile duct for the treatment of strictures or stones. The pancreatic ductal system, however, is more difficult to approach in such situations. In selected cases, direct pancreatography may be possible via a percutaneous 2 Opacic M Rustemovic N Pulanic R Vucelic B Frkovic M Mandic A Percutaneous pancreatography under ultrasonographic guidance. Acta Radiol. 1996; 37: 75-78 PubMed Google Scholar or EUS-guided approach. 3 Harada N Kouzu T Arima M Asano T Kikuchi T Isono K Endoscopic ultrasound-guided pancreatography: a case report. Endoscopy. 1995; 27: 612-615 Crossref PubMed Scopus (67) Google Scholar , 4 Gress F Ikenberry S Sherman S Lehman G Endoscopic ultrasound-directed pancreatography. Gastrointest Endosc. 1996; 44: 736-739 Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar However, therapeutic manipulations of the pancreatic duct may require extensive surgical exploration. Two patients are described with surgically altered anatomy of the upper GI tract in whom pancreatography and endoscopic manipulation of the pancreatic duct was performed via intraoperative transjejunal ERCP. Technical aspects of this procedure are described, and its potential use is discussed.

Common bile duct stones: The role of preoperative, intraoperative, and postoperative ERCP

Common bile duct stones: The role of preoperative, intraoperative, and postoperative ERCP

Intraoperative ERCP and endoscopic sphincterotomy combined with laparoscopic cholecystectomy for treatment of cholelithiasis with choledocholithiasis

Objective: To evaluate the benefit of intraoperative ERCP and endoscopic sphincterotomy (EST) combined with laparoscopic cholecystectomy (LC) in the treatment of cholelithiasis with choledocholithiasis. Methods: Fifty-two patients with cholelithiasis and choledocholithiasis (as determined by intraoperative cholangiography) were randomly divided into 2 groups during LC. In group A (27 patients), common bile duct stones were extracted by intraoperative EST during LC. In group B(25 patients), common bile duct (CBD) stones were extracted by conversion to open CBD exploration and cholecyctectomy. Results: The success rate was 26/27 (96.3%) in group A and 25/25 (100%) in group B (0.25<P<0.5); The mean postoperative hospitalization was 3.32±0.56 days in group A and 17.5±4.61 days in group B (P<0.001). In group A, two cases were complicated transient hyperamylasemia after the combined procedure. In group B, one case of bile leakage and one case of duodenal ulcer occurred after conversion to open cholecystectomy with CBD exploration. There were no retained stones in group A but 2 cases in group B. Conclusion: Intraoperative ERCP and endoscopic sphincterotomy combined with LC for treatment of cholelithiasis and chiledochlithiasis is safe, effective and results in shorter hospitalization and fewer complications than traditional open cholecystectomy with CBD exploration.

7251 Natural history of asymptomatic bile duct stones at time of cholecystectomy.

There is relatively little data on the natural history of asymptomatic bile duct stones. As there is currently uncertainty on the management of asymptomatic bile duct stones at time of laparoscopic cholecystectomy, we followed up a group of patients over a 5-year period. METHODS: We followed up 59 patients who underwent laparoscopic cholecystectomy (study group). None of these patients had a pre-operative suspicion of bile duct stones and therefore no intra-operative cholangiogram or ERCP was performed pre or post surgery. Follow up was in the form of a telephone questionnaire to their respective primary care physicians. The control group had no pre-operative suspicion of bile duct stones but had routine intraoperative cholangiogram performed. RESULTS: 59 patients were followed up for an average of 57 months (4.8 years)(range 30-78 months) after laparoscopic cholecystectomy. Mean age was 52yrs (range 31-84yrs). 4 patients had seen their primary care physicians with symptoms of gastroesophageal reflux disease. 2 patients were diagnosed with duodenitis following EGD. 1 patient had been referred for barium enema for lower abdominal pain and diagnosed with diverticulitis. 1 patient had ongoing nausea. 1 patient had continuing right upper quadrant pain, which was diagnosed as neuropathic pain, and referred to the pain clinic. None of the patients had pancreatitis, jaundice, deranged liver function tests, ERCP or other biliary investigations. In the control group, intra-operative cholangiogram was performed in 73 patients without suspected bile duct stones. 4 of 73 (6%) patients had intraductal stones detected, which were removed either endoscopically or, by surgery. CONCLUSIONS: The prevalence of asymptomatic bile duct stones during time of cholecystectomy in our population was 6% i.e. we would expect 3 patients in our study group to have asymptomatic bile duct stones.We found that the study group had no complications related to bile duct stones during the 5-year follow up period. This would support the view that incidental bile duct stones found in patients undergoing laparoscopic cholecystectomy do not need removed.

Biliary tract complications in laparoscopic cholecystectomy. A multicenter study of 148 biliary tract injuries in 26,440 operations.

The higher risk of biliary tract injury is considered the most significant disadvantage of laparoscopic cholecystectomy. A national multicenter retrospective study was performed to determine the frequency, etiology, and treatment of biliary tract injuries between January 1, 1991, and December 31, 1994. Follow-up was by questionnaire. Some 148 biliary tract complications were observed during 26,440 laparoscopic cholecystectomies. There was no significant correlation found between the number of LCs performed in one institute and the incidence of biliary tract injuries and postoperative bile leakage, but in the 2nd year of practice, the incidence of both complications decreased. In institutes with more conversions, more cases of bile leakage were also observed. A significant positive relationship was found between biliary tract injuries and postoperative bile leaks. There was no significant relationship between usage of intravenous and intraoperative cholangiography and ERCP. In univariant analysis of the type of injury, the primary treatment modality did not affect the outcome of injury or entail the necessity of reoperation. Obscure anatomy leads to significantly more main bile duct injuries. According to multivariant analysis, the outcome is significantly influenced unfavorably by the necessity of repeated interventions and advanced age. The definitely higher risk of bile duct injury mentioned in early studies was not confirmed.

Innervation Patterns in Congenital Biliary Dilatation*

The innervation of choledochal cysts was studied to see if the distribution of innervating ganglion cells can be utilized as a possible indicator of the damage and dilatation process of choledochus. Specimens from 32 patients aged 1 month to 12 years were stained by the immunoperoxidase method with neural tissue-specific antibodies, the innervating ganglion cells were counted and their number was correlated with the clinical severity, patient's age-at-surgery, and intraoperative cholangiographic and/or ERCP findings. In cystic dilatation, the total number of ganglion cells within the choledochal wall was significantly lower than in control specimens regardless of the diameter of the choledochal cyst, age-at-surgery, or clinical course. In fusiform dilatation, the total number of ganglion cells varied according to the severity of the clinical presentation, and the diameter of the fusiform choledochus increased in proportion to the patient's age-at-surgery. The distribution of innervating ganglion cells is thought to correlate quantitatively with the damage and dilatation process responsible for the choledochal cyst. These results may support a hypothesis that the pathogenesis of cystic dilatation proceeds antenatally or soon after birth, while that of fusiform dilatation begins after birth.