Management Of Cholelithiasis Research Articles

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.

Reoperation of Biliary Tract by Laparoscopy

Background: Patients with previous operation of biliary tract were considered in the past as a contraindication to perform reoperation by laparoscopy. As experience with laparoscopic techniques and instrumentation has expanded, laparoscopic reoperation of biliary tract has become an accepted procedure in the management of cholelithiasis. Here we introduce our interesting experience with regard to reoperation of biliary tract by laparoscopy. Methods: Laparoscopic operation of biliary tract was performed on 3,674 consecutive patients from April 1992 to June 2005. Among these patients, 26 had a previous open operation of biliary tract whose clinical data were analyzed retrospectively: seven cases had complicated intrahepatic bile duct stones (restricted at hepatic duct of the first and the 2nd order) ; Diameter of common bile duct in patients with common duct stones was above 1.2 cm and the numbers of stones from each patient was more than 3 and the biggest stone exceeded 1 cm. All 26 patients were preoperatively excluded to present stenosis of bile duct and malignant tumor by both radiological examination and detection of serological tumor markers.Results: The mean operative time was 125 min (75–190 min). Reoperations of biliary tract by laparoscopy were successfully accomplished in 25 patients. One patient was converted to open operation whose common duct stones were taken out by right angle forceps through a short incision. None of the patients developed any severe complication and all of them recovered and were discharged. Three cases with retained calculus were successfully cured by taking them out through the sinus tract of T tube.Conclusions: Laparoscopic procedure is minimally invasive, is safe and feasible for reoperation of the biliary tract. And it is a first choice method for cases to whom endoscopic sphincterotomy is contraindicated.

Laparoscopic cholecystectomy for cholelithiasis in children

Aim:To evaluate the role of laparoscopic cholecystectomy (LC) in the management of cholelithiasis in children.Methods:A retrospective review of our experience with LC for cholelithiasis at our institution, between April 2006 and November 2008, was done. Data included patient demographics, clinical history, hematological investigations, imaging studies, operative technique, postoperative complications, postoperative recovery, and final histopathological diagnosis.Results:During the study period of 32 months, 18 children (8 males and 10 females) with cholelithiasis were treated by LC. The mean age was 9.4 years (range 3–18). Seventeen children had symptoms of biliary tract disease and 1 child had incidentally detected cholelithiasis during an ultrasonography of abdomen for unrelated cause. Only 5 (27.8%) children had definitive etiological risk factors for cholelithiasis and the remaining 13 (75.2%) cases were idiopathic. Sixteen cases had pigmented gallstones and 2 had cholesterol gallstones. All the 18 patients underwent LC, 17 elective, and 1 emergency LC. The mean operative duration was 74.2 min (range 50–180). Postoperative complications occurred in 2 (11.1%) patients. The average duration of hospital stay was 4.1 days (range 3–6).Conclusion:Laparoscopic chloecystectomy is a safe and efficacious treatment for pediatric cholelithiasis. The cause for increased incidence of pediatric gallstones and their natural history needs to be further evaluated.

Management of cholelithiasis in Italian children: A national multicenter study

To evaluate the management of Italian children with cholelithiasis observed at Pediatric and Surgical Departments linked to Italian Society of Pediatric Gastroenterology Hepatology and Nutrition. One-hundred-eighty children (90 males, median age at diagnosis 7.3 years; range, 0-18 years) with echographic evidence of cholelithiasis were enrolled in the study; the data were collected by an anonymous questionnaire sent to participating centers. One hundred seventeen patients were treated with ursodeoxycholic acid; in 8 children dissolution of gallstones was observed, but the cholelithiasis recurred in 3 of them. Sixty-five percent of symptomatic children treated became asymptomatic. Sixty-four patients were treated with cholecystectomy and in only 2 cases a postoperative complication was reported. Thirty-four children received no treatment and were followed with clinical and echographic controls; in no case the development of complications was reported. The therapeutic strategies were extremely heterogeneous. Ursodeoxycholic acid was ineffective in dissolution of gallstones but it had a positive effect on the symptoms. Laparoscopic cholecystectomy was confirmed to be an efficacy and safe treatment for pediatric gallstones.

Mini-open cholecystectomy in the management of cholelithiasis.

To analyze the outcome of open mini-cholecystectomy in terms of operative success and complications. Retrospective review of record. Shifa International Hospital, Islamabad, from January 2002 to September, 2005. All the patients who underwent mini-open cholecystectomy for cholelithiasis during the study period were reviewed. The data was collected on a computerized proforma. The patients undergoing classical open cholecystectomy were excluded. Statistical analysis was performed using SPSS for Windows version 11. A total of 200 cases were operated (180 females, 20 males; M:F ratio 1:9). The mean age was 43 years (range 21-72 years). The average operating time was 45 minutes. Complications included biliary leak in one patient (0.5%), bleeding 1 (0.5%), wound infections 4 (2%) and death in one case (0.5%). The overall rate of complications was 3.5%. There were 5 patients who required extension of the incision for reasons like carcinoma gallbladder (1), control of bleeding (1), bad adhesions (1), difficult anatomy (1) and biliary leak from the liver bed (1). The mean hospital stay was 1.5 days (range 1-3 days). Mini-open cholecystectomy appears to be a safe and has its application where laparoscopic facilities are not available.

Reoperation of Biliary Tract by Laparoscopy: a Consecutive series of 26 Cases

Background: In the past, previous operation of biliary tract represented a contraindication to perform reoperation by laparoscopy. As experience with laparoscopic techniques and instrumentation has expanded, reoperation of biliary tract with laparoscope has become an accepted procedure in the management of cholelithiasis. We present our interesting experience with regard to reoperation of biliary tract by laparoscopy.Material and methods: Laparoscopic operation of biliary tract was performed on 3,674 consecutive patients from April, 1992 till June, 2005. Among these patients, 26 had a previous open operation of biliary tract and their clinical data were retrospectively analyzed as follows: seven cases had complicated intrahepatic bile duct stones (restricted at hepatic duct of the first and second order). Diameter of common bile duct in patients with common duct stones was above 1.2 cm, the number of stones for each patient was more than 3 and all the biggest stones exceeded 1 cm. In the 26 patients, pre-operatively, stenosis of bile duct and malignant tumour were excluded by both radiological examination and detection of serological tumour markers.Results: The mean operative time was 125 min (75–190 min). Reoperations of biliary tract by laparoscope were successfully accomplished in 25 patients. One patient was converted to open operation and the common duct stones were removed by right angle forceps through short incision. None of the patients developed any severe complication, all of them recovered and were successfully discharged. Three cases with retained calculuses were successfully cured by removing these through the sinus tract of T tube.Conclusions: Laparoscopic procedure is minimally invasive, safe and feasible for laparoscopic experts in case of reoperation of biliary tract. It is also a first method for patients for whom endoscopic sphincterotomy is contraindicated.

Laparoscopic Cholecystectomy for Renal Transplants

The diagnosis and management of cholelithiasis in renal transplant patients are subjects of debate. The purpose of this study was to evaluate the outcomes of laparoscopic cholecystectomy in renal transplant patients with symptomatic gallstone disease. The records of 155 kidney transplant patients were reviewed, including 16 patients who, underwent laparoscopic cholecystectomy. Shortest interval time between transplantation and cholecystectomy was 2 years. Surgical morbidity were seen in two patients (12.5%) with no mortality and no graft loss. In conclusion, laparoscopic cholecystectomy can be performed safely with low morbidity in renal transplant patients who have symptomatic gallstone disease. The morbidity rate is comparable to nontransplant patients.

Two-stage versus single stage management of cholelithiasis and common bile duct stones: A prospective, randomized trial

Two-stage versus single stage management of cholelithiasis and common bile duct stones: A prospective, randomized trial

Cholelithiasis in pediatric organ transplantation: detection and management.

The real incidence and the underlying causes of cholelithiasis in pediatric solid organ recipients is probably not exactly known. In addition to well-established risk factors for cholelithiasis, children after heart, kidney, or liver transplantation may develop gallstones due to drug therapy, sepsis, parenteral nutrition, or surgical complications. For pediatric patients, data are very limited and heterogeneous. However, the incidence in pediatric heart recipients seems to be substantially higher compared with kidney or liver graft recipients. In this review article the present data are discussed focusing on incidence, detection, and management of cholelithiasis in pediatric organ transplantation. In general, surgery is the therapy of choice in symptomatic patients; however, the pharmacological profile of ursodeoxycholic acid and the first results on its clinical impact are promising. The value of prophylactic therapy with ursodeoxycholic acid must be determined in further studies.

Management of cholelithiasis in pediatric patients who undergo bone marrow transplantation

The aim of this study was to determine the incidence, risk factors, and proper management for asymptomatic cholelithiasis in children undergoing bone marrow transplantation (BMT). The authors reviewed retrospectively the records of 575 children who underwent bone marrow transplantation at a University bone marrow transplantation unit (BMT) unit between February 1991 and October 1999. Of these patients, 235 underwent abdominal ultrasonography for evaluation of jaundice, sepsis, abdominal pain, or metastasis. To identify risk factors for cholelithiasis, the authors stratified the patients based on their disease and treatment regimen. Finally, the authors analyzed the natural history and management of BMT children with cholelithiasis. The authors identified 20 cases of cholelithiasis (8.5%) in the 235 BMT patients who underwent ultrasonography. Children who underwent BMT to treat bone marrow failure showed a significantly increased risk of cholelithiasis compared with children treated for malignancy (27% v 7.4%; P<.01). Most children (85%) with gallstones did not require surgical intervention. Specifically, 9 (45%) died from their primary disease, 5 (25%) showed sonographic resolution of their gallstones, and 3 (15%) underwent follow-up nonoperatively with persistent cholelithiasis. Three of the 20 patients with gallstones (15%) had signs of acute cholecystitis and underwent surgery. There were no surgical complications or deaths in the operative group. Cholelithiasis occurs at a high incidence in pediatric bone marrow transplant patients. Children undergoing BMT for bone marrow failure are at higher risk of having gallstones than those being treated for malignancy. Finally, these data support a strategy of nonoperative management for asymptomatic cholelithiasis in this highly selected group of patients.

Management of cholelithiasis in combination with cardiovascular surgery

A retrospective review of the perioperative management of patients with cardiovascular surgical disorders and cholelithiasis was conducted, and the surgical strategies employed are discussed. Between 1988 and 1998, 18 patients having cardiovascular surgical disorders underwent cholecystectomy. These patients were divided into three groups: group I, given a one-stage operation (n = 9); group II, given a two-stage operation (n = 3); and group III, given cholecystectomy during follow-up after cardiovascular surgery (n = 6). In group I, a median laparotomy was adopted for patients with an abdominal aortic aneurysm (AAA) to allow both disorders to be treated through the same incision, whereas a right subcostal approach was employed to separate the incisions for patients who underwent cardiac operations. In group II, one patient underwent cholecystectomy before cardiac surgery, and two patients underwent cholecystectomy for postoperative cholecystitis after cardiovascular operations. One patient from group II and all from group III were on preoperative anticoagulant therapy, two of whom underwent laparoscopic cholecystectomy. No fatal complications such as prosthetic infection, intraperitoneal hemorrhage, or cerebral attack were encountered. In conclusion, we consider that performing cholecystectomy during AAA repair may be safe and prevents the risk of postoperative cholecystitis; it is preferable to treat cholelithiasis coexisting with cardiac disorders concomitantly with or before cardiac operations; and laparoscopic cholecystectomy can be safely performed under anticoagulant therapy.

Laparoscopic common bile duct exploration by choledochotomy. An effective and efficient method of treatment of choledocholithiasis.

Management of cholelithiasis and choledocholithiasis usually requires two separate teams-the gastroenterologist/surgical endoscopist and the laparoscopic surgical team. This requires two separate procedures that potentially increase the overall morbidity and cost. Laparoscopic common bile duct exploration by choledochotomy (LCBDE-C) averts this problem with a single approach. In 1990-1991, unsuspected stones found at laparoscopy with intraoperative cholangiogram done routinely underwent postoperative ERCP. Residual stones had been found after ERCP in 16 of 22 preoperative ERCP patients and we began to seek an alternative technique. Laparoscopic common bile duct exploration by choledochotomy has achieved a high rate of success. Technically successful LCBDE-C has been accomplished in 143 of 148 patients (96.6%). Retained bile duct stones have been found on postoperative cholangiogram in three patients (2.0%), all of which have been successfully removed by postoperative ERCP. Thus 140 or 148 patients had their bile duct successfully cleaned by the one-step technique alone (94.6%). We believe that most laparoscopic surgeons who have acquired the skills of intracorporeal suturing can be successful at laparoscopic common bile duct exploration by choledochotomy. The disadvantage of T-tube presence will likely be eliminated by future developments with intraoperative antegrade sphincterotomy-like procedures, but the ability to see both proximal and distal biliary tree with the choledochotomy in all cases seems to offer more than adequate results at this point in the evolution of the laparoscopic approach to calculus biliary tract disease.

Sequential endoscopic/laparoscopic management of sickle hemoglobinopathy-associated cholelithiasis and suspected choledocholithiasis.

We reviewed the medical records of 17 patients with sickle hemoglobinopathy-associated cholelithiasis who were candidates for laparoscopic cholecystectomy (LC) between 1991 and 1994. Eight patients with suspected choledocholithiasis (CDL) were identified, all of whom had preoperative endoscopic retrograde cholangiopancreatography (ERCP), which revealed CDL in 3 patients (18%), all of whom had endoscopic ductal clearance. Choledocholithiasis was suspected because of hyperbilirubinemia or serum liver enzyme abnormalities. Incremental hyperbilirubinemia exceeding "baseline" values by > 5 mg/dL was the best predictor of CDL. Subsequent LC was successful with discharge within 2 days of LC in all but one patient, who was converted to open cholecystectomy. This small series suggests that in sickle hemoglobinopathy patients with cholelithiasis (1) CDL is relatively common among patients with an increase above baseline hyperbilirubinemia, (2) bile duct dilatation, alkaline phosphatase, and serum aminotransferase levels are poor predictors of CDL, and (3) sequential endoscopic/laparoscopic management of cholelithiasis and suspected CDL is successful.

Combined laparoscopic and endoscopic management of cholelithiasis and choledocholithiasis

Combined laparoscopic and endoscopic management of cholelithiasis and choledocholithiasis

Impact of laparoscopic cholecystectomy on the management of cholelithiasis in children with sickle cell disease

Children with sickle cell disease, well known to have a high incidence of cholelithiasis, are frequently admitted to the hospital for episodes of abdominal pain. Before the advent of laparoscopy, few children with sickle cell and cholelithiasis underwent cholecystectomy unless absolutely necessary, because of the high morbidity of an open cholecystectomy (OC). We reviewed our records of all children with sickle cell disease and cholelithiasis treated from 1985 to 1992 to investigate the impact of laparoscopic cholecystectomy (LC). During that period, 32 children underwent cholecystectomy: 10 OC and 22 LC (all since December 1990). Before December 1990, all children had either classic biliary tract symptoms or abdominal pain of unknown etiology. However, of the 22 LC children, five had asymptomatic cholelithiasis. Only three of the 32 patients had choledocholithiasis, although 30 of 32 had elevated total bilirubins. Two LC children presented with choledocholithiasis and were initially treated with endoscopic sphincterotomy and stent placement. A standard intraoperative cholangiogram (IOC) through the cystic duct was performed in all OC cases. In 19 of 22 LC cases, an IOC through the gallbladder was performed before any dissection; unsuspected choledocholithiasis was not found, but the IOC did allow visualization of the course of the cystic duct, facilitating its subsequent dissection. Total operative length was comparable between the two groups, but the LC patients' postoperative length of stay was half that of the OC patients (2.1 v 4.6 days). Postoperative complications in the OC group included three children who had severe pain, atelectasis, fever, and hypoxemia (30%). In the LC group, one child experienced ventricular ectopy requiring ICU monitoring, and another had atelectasis and hypoxemia (9%). To date there have been no bile duct complications in the LC group. Thus, LC has proven to be a safe and efficacious technique in this high-risk patient population. Realizing this, our pediatric hematologists now aggressively investigate the biliary tracts of their patients who have sickle cell, and have begun to refer them for surgery before the development of biliary tract symptoms.

Approaches to the management of cholelithiasis for the medical consultant

Gallstones constitute a major medical problem in the United States. Patients who are asymptomatic require no therapy. Subsequent symptoms develop in a minority of patients, and the need for cholecystectomy is low. Symptomatic patients with reversible risk factors for gallstones, those who refuse surgery, and those who are poor surgical candidates should be considered for medical therapy. Our approach is outlined in Figure 2. Practical options include oral dissolution agents, contact dissolution agents, and shock-wave lithotripsy. Unfortunately, these therapies are successful in very select patients, and only a small percentage of patients with symptomatic gallstones will be candidates for any combination of these. If successful, the recurrence rate is high. Cholecystectomy is a safe, effective procedure that definitively treats symptomatic cholelithiasis. Patients with frequent symptoms of biliary colic, those with severe symptoms, and those who are young and do not have reversible risk factors for gallstones should be considered for cholecystectomy. If surgical expertise is available, the patient requiring an elective cholecystectomy should be educated regarding the laparoscopic approach that offers a better cosmetic result, shorter hospital stay, and faster return to normal activities. The medical consult must be aware of all the options available for managing patients with cholelithiasis. This will afford greater versatility in medical care or perioperative management.

Nonsurgical Management of Cholelithiasis

Nonsurgical Management of Cholelithiasis

Nonsurgical management of cholelithiasis

Nonsurgical management of cholelithiasis

LAPAROSCOPIC CHOLECYSTECTOMY INITIAL EXPERIENCE

Twenty-five consecutive patients underwent percutaneous laparoscopic cholecystectomy (PCC). The gallbladder was removed successfully in 18 patients. The mean postoperative hospital stay was 1.4 days and patients returned to normal activity at a mean 8 days after operation. Postoperative pain was minimal. Formal laparotomy was performed in 7 patients due to: bleeding (3 patients), stone spillage (3 patients) and exploration of the common bile duct (1 patient). Complications were reduced with experience and strict adherence to the described operative technique. With obvious advantages for the patient, hospitals and the community an increased demand for PCC is inevitable. However, its role in the management of cholelithiasis and overall safety have yet to be determined. There is a significant learning curve and proper training is necessary. The widespread introduction of PCC has immediate implications for surgical training.

Nonsurgical Management of Cholelithiasis

Cholecystectomy is accepted and effective therapy for symptomatic cholelithiasis; until recently, it was the only therapeutic option for patients with gallstones. Recently available alternative therapy for cholelithiasis includes oral dissolution therapy with the bile salts ursodeoxycholic acid and chenodeoxycholic acid, extracorporeal shock wave lithotripsy, and instillation of methyl tert-butyl ether directly into the gallbladder. The role of each of these methods in the treatment of patients with gallstones will be reviewed, as well as the epidemiology, pathogenesis, natural history, and roentgenographic characteristics of gallstones, all of which are relevant when choosing appropriate therapy for the individual patient.