Postoperative Endoscopic Retrograde Cholangiopancreatography Research Articles

Liver Function Tests after Laparoscopic Common Bile Duct Exploration Are Not Reliable

INTRODUCTION: Laparoscopic common bile duct exploration (LCBDE) to manage choledocholithiasis at the time of cholecystectomy (LC+LCBDE) is gaining traction and requires examination of the role of postoperative laboratory data to guide clinical care. We examined postoperative liver function test (LFT) trends in the context of successful and failed LCBDE. METHODS: Retrospective review of all adult emergency general surgery (EGS) patients undergoing LCBDE over a 3-year period. Failed LC+LCBDE was defined as the subsequent need for endoscopic retrograde cholangiopancreatography (ERCP) for duct clearance. Postoperative LFTs from both successful and failed LCBDE attempts were analyzed. Postoperative laboratory values from all LC+LCBDE were classified as increased, decreased, or unchanged from preoperative. Procedure outcomes were analyzed. RESULTS: Sixty patients underwent LCBDE. Ten patients were excluded for not having preoperative laboratory tests or any postoperative laboratory tests. Thirty-three of the remaining 50 patients had 2 sets of postoperative laboratory tests. In patients who underwent successful LCBDE, there was no statistical difference (p > 0.05) between the preoperative and the 1st postoperative or 2nd postoperative laboratory tests regarding total bilirubin, aspartate/alanine aminotransferase, or alkaline phosphatase. For patients who had an unsuccessful LCBDE and required postoperative ERCP, this was also true. No patients with successful LCBDE with increased postoperative laboratory tests had complication. CONCLUSION: Despite the LCBDE outcome, postoperative laboratory tests do not provide reliable prognostication as would be expected in the given clinical context. Contrast flow into the duodenum and surgeon judgment are better indicators of duct clearance. It is safe to discharge patients without LFT after successful and uneventful LCBDE.

Outcomes following common bile duct exploration versus endoscopic stone extraction before, during and after laparoscopic cholecystectomy for patients with common bile duct stones

BackgroundLaparoscopic common bile duct exploration (LCBDE) and endoscopic retrograde cholangiopancreatography (ERCP) are two methods of retrieving common bile duct (CBD) stones. The best method for CBD stone removal is debatable. The aim of this study was to compare outcomes following LCBDE and/or ERCP, including laparoscopic cholecystectomy. MethodsData were collected retrospectively for patients undergoing LCBDE and/or ERCP at a single centre from 2008 to 2018. Patients were grouped by intention-to-treat (single-stage LCBDE, pre-operative-, intra-operative-, or post-operative ERCP) and eventual plan (surgical or endoscopic). Outcomes included complication rates (minor Clavien-Dindo 1/2, major Clavien-Dindo 3/4, non-biliary complications) and mortality. ResultsOf 671 patients, 578 patients received LCBDE and 93 patients received ERCP as primary care. Endoscopic clearance had significantly higher complications and mortality compared to surgical clearance. On an intention-to-treat basis LCBDE had the lowest minor-, major- and non-biliary complications, and mortality (5.2%, 6.1%, 2.9% and 0.5%, respectively), whilst pre-operative ERCP the worst (39.6%, 27.1%, 29.2% and 8.3%, respectively) (p=<0.001). LCBDE and postERCP had similar major complications and mortality. ConclusionSurgical clearance of CBD stones was potentially safer than endoscopic clearance. Pre-operative ERCP had the worst outcomes. LCBDE and postERCP are likely to have similar short-term patient outcomes.

Laparoscopic Common Bile Duct Clearance, is It Feasible and Safe After Failed Endoscopic Retrograde Cholangiopancreatography?

Introduction: Concomitant gallstones and common bile duct (CBD) stones is a common problem, and there is still no consensus on the best approach in the management. Options include preoperative endoscopic retrograde cholangiopancreatography (ERCP), Laparoscopic cholecystectomy (LC) with CBD exploration, and LC with postoperative ERCP. Each option has its own limitations and complications. In this article, we assessed the feasibility of laparoscopic surgical clearance of the CBD after a failed ERCP, reasons for failure of endoscopic clearance in our cohort. We will discuss the management options after ERCP failure, the challenges, and the outcomes. Materials and Methods: We retrospectively reviewed all the cases of laparoscopic common bile duct exploration (LCBDE) performed in our hospital between April 2006 and January 2019. Two hundred cases were performed, 178 cases as a primary procedure while 22 were performed as a secondary procedure after failed ERCP. We have previously published data on the case series (PMID 33140155) and here explored the cases performed after failed ERCP as a secondary procedure. We analyzed demographics of patients, preoperative investigations, ERCP trials, and reasons for ERCP failure, operative approach, duration of operation, conversion rate, complications, and outcomes. Results: Twenty-two patients underwent a laparoscopic CBD clearance after failed ERCP. Sixteen of these were in the first 5 years of the study. Multiple attempts of ERCP were made in 7 patients (31.8%) and a single attempt in 15 patients. In 8 patients (32%), the duct was not accessible (failed cannulation) due to a variety of reasons. Nine patients had impacted stones larger than 1 cm, 4 patients had Mirrizi syndrome with concomitant large CBD stones, and 1 patient failed endoscopic clearance because of the large number of stones in the CBD. CBD clearance was successful in 19 patients (88%), 8 were completed by a transcystic approach and 14 by a transcholedochal approach. Postoperative length of stay was 12 (+10) days. One patient had an unplanned readmission within 30 days. One patient required reoperation for bleeding. Three patients developed recurrent stones and 1 developed a subsequent stricture. No mortalities were recorded. Conclusion: LCBDE is feasible and appears safe as a secondary procedure after failed ERCP. The new technologies and the advancement of surgical techniques will continue to improve success and reduce morbidity.

Laparoscopic common bile duct exploration by acute care surgeons saves time and money compared to ERCP

BackgroundA typical pathway for treatment of choledocholithiasis (CD) in emergency general surgery patients involves same admission laparoscopic cholecystectomy (LC) with either preoperative or postoperative endoscopic retrograde cholangiopancreatography (ERCP). The goal of this study was to describe our initial experience at a safety net hospital with acute care surgeon-performed laparoscopic common bile duct exploration (LCBDE) when CD is confirmed at the time of LC. We hypothesized that this strategy would result in reduced length of stay, and lower charges compared to ERCP. MethodsThis was a retrospective case control study over a 2 year period matching LCBDE to ERCP (1:3) among a cohort of patients with CD confirmed at first procedure. Data is reported as median (interquartile range). Statistical analysis used the Kruskal-Wallis and Chi-squared tests with 95% confidence interval. ResultsDemographics, preoperative WBC, and bilirubin were similar between the LCBDE (n = 14) and ERCP (n = 37) groups. Success rate for LCBDE was 11/14 (79%), and the remaining three subjects successfully underwent post-operative ERCP. Overall complication rate for the LCBDE group was 1/14 (7%) and the readmission rate was 0/14 (0%). Length of stay for LCBDE vs ERCP was 2.5 (1–3) vs 5 (3–5) days (p < 0.01). Charges during initial hospitalization was $35858 ($26587-$49570) vs $48662 ($36018-$57106) (p = 0.05). ConclusionsLCBDE by acute care surgeons at the time of LC was associated with lower charges, reduced hospital length of stay, low rates of post-operative complications, and no readmissions.

Inpatient Choledocholithiasis Management: a Cost-Effectiveness Analysis of Management Algorithms

BackgroundCholedocholithiasis is commonly encountered. It is frequently managed with laparoscopic common bile duct exploration or endoscopic retrograde cholangiopancreatography (either preoperative, intraoperative, or postoperative relative to laparoscopic cholecystectomy). The purpose of this study is to determine the most cost-effective method to manage inpatient choledocholithiasis. MethodsA decision tree model was created to evaluate the cost-effectiveness of laparoscopic common bile duct exploration and preoperative, intraoperative, and postoperative endoscopic retrograde cholangiopancreatography. The primary outcome was incremental cost-effectiveness ratio with a ceiling willingness to pay threshold assumed of $100,000 per quality-adjusted life year. Model parameters were determined through review of published literature and institutional data. Costs were from the perspective of the healthcare system with a time horizon of 1 year. Sensitivity analyses were performed on model parameters. ResultsIn the base case analysis, laparoscopic common bile duct exploration was cost-effective, resulting in 0.9909 quality-adjusted life years at an expected cost of $18,357. Intraoperative endoscopic retrograde cholangiopancreatography yielded more quality-adjusted life years (0.9912) at a higher cost ($19,717) with an incremental cost-effectiveness ratio of $4,789,025, exceeding the willingness to pay threshold. Both preoperative and postoperative endoscopic retrograde cholangiopancreatographies were eliminated for being both more costly and less effective. Laparoscopic common bile duct exploration remained cost-effective if the probability of successful biliary clearance was above 0.79, holding all other variables constant. If its base cost remained below $18,400 and intraoperative endoscopic retrograde cholangiopancreatography base cost rose above $18,200, then laparoscopic common bile duct exploration remained cost-effective. ConclusionLaparoscopic common bile duct exploration is the most cost-effective method to manage choledocholithiasis. Efforts to ensure availability of local expertise and resources for this procedure are warranted.

Outcomes Following Common Bile Duct Exploration versus Endoscopic Stone Extraction Before, during and after Laparoscopic Cholecystectomy for Patients with Common Bile Duct Stones

Introduction: Common bile duct exploration (CBDE) and endoscopic retrograde cholangio-pancreatography (ERCP) are two methods of retrieving common bile duct (CBD) stones. There is debate as to the best method for removal of CBD stones. The aim of this study was to compare outcomes following CBDE and/or ERCP. Methods: Data were collected retrospectively for patients undergoing CBDE and/or ERCP at a single centre from 2008-2018. Patients were grouped based on initial operative plan (single stage CBDE, pre-operative-, intra-operative-, or post-operative ERCP). Complication rates (minor Clavien-Dindo 1/2, major Clavien-Dindo 3/4), success, number of procedures, and length of stay were recorded. Results: Of 678 patients, 578 patients received CBDE first and 100 patients received ERCP as primary care. Pre-operative ERCP was associated with a significantly higher number of complications (minor 24% and major 18%) and lower success. The CBDE and post-op ERCP groups had similar morbidity (minor 5.2% vs 6.1%, and major 5.0% vs 5.0%). However, there was a significantly higher median number of procedures for post-op ERCP and longer length of stay. When both ERCP and CBDE were used there was significantly higher major (20.7%) and minor complications (27.6%). Conclusion: Pre-operative ERCP for stone clearance is associated with significantly high morbidity and had similar rates to those who failed initial treatment and underwent both CBDE and ERCP. Although morbidity and mortality for CBDE and post-operative ERCP groups are similar, post-operative ERCP is associated with longer length of stay and higher number of procedures, suggesting patient and economic advantages in single stage CBDE.

A combined endoscopic and robotic approach for Mirizzi syndrome: the short- and long-term outcomes

Aims: We present the technique of a combined endoscopic and robotic approach for Mirizzi syndrome (MS) and report the short- and long-term results. Methods: Between July 2012 and August 2020, all patients with suspected MS underwent endoscopic retrograde cholangiopancreatography (ERCP) for diagnostic confirmation and placement of the biliary stent. Subtotal cholecystectomy was then performed with the assistance of a surgical robot. The common bile duct was closed with a cuff of the gallbladder over a biliary stent. ERCP was repeated 6-8 weeks after surgery to remove the biliary stent and confirm the patency of common bile duct. The operative outcomes and long-term results were prospectively collected. Results: Twenty-two patients (10 males and 12 females) were included in the study. All patients underwent the planned robotic subtotal cholecystectomy and pre- and postoperative ERCP. The median age was 65.5 years (range 16-89 years). The median operative time was 212.5 min (range 125-510 min), and the median blood loss was 35 mL (range 7-700 mL). The median postoperative hospital stay was four days (range 3-15 days). Four patients (18.2%) developed postoperative complications including two intra-abdominal collections (9.1%), one wound infection (4.5%), and one atrial fibrillation with pneumonia (4.5%). The last patient also represented the only operative mortality. The median follow-up was 45.6 months; none developed recurrent cholangitis or jaundice, but one patient (4.5%) had a recurrent common bile duct stone which was successfully removed by ERCP. Conclusion: The proposed combined endoscopic and robotic approach can provide favorable short- and long-term outcomes for patients with MS.

The Clinical Significance of Hemorrhagic Cholecystitis.

Background:Hemorrhagic cholecystitis (HC) is a rare complication of acute cholecystitis. HC is difficult to diagnose pre-operatively and previous case reports suggest a strong association with anticoagulation and an increased morbidity. The purpose of the study is to determine the clinical presentation and outcomes of patients with HC in a large cohort of patients.Method:A retrospective review of HC patients diagnosed following review of the clinical and pathological database between January 1, 2000 – June 30, 2021 at two hospitals. A search of the histopathology database, patient medical records, laboratory results, and imaging was conducted.Results:Thirty-five patients were diagnosed on the histopathology report from approximately 6458 patients who had cholecystectomies. Thirty-one had emergency presentation and four patients (11.4%) had elective surgery. Twenty-one patients (60%) were female and 15 patients (40%) were male. The median age was 51 years. All patients had laparoscopic cholecystectomy, four patients were converted to open and five patients required postoperative endoscopic retrograde cholangiopancreatography. Two patients (5.7%) were on anticoagulation therapy. Twenty-three (65.7%) had ultrasound, 12 patients (34.2%) had computed tomography, three patients (8.5%) had magnetic resonance cholangiopancreatography, and one patient with a pre-operative diagnosis of HC.Conclusion:HC is a rare form of acute cholecystitis. Anticoagulation only accounts for a small fraction of these patients. Pre-operative diagnosis of HC is not often made. Patients were treated with cholecystectomies and made a full recovery with no complications. Our study seems to show HC is a histological diagnosis with no clinical consequences for the patients.

Management of complicated biliary disease in the pediatric population

Cholesterol stones and biliary dyskinesia have replaced hemolytic disease as the primary indication for pediatric cholecystectomy. This study looks at the cohort of pediatric patients with complicated biliary disease, defined as choledocholithiasis and/or gallstone pancreatitis, to determine the incidence and best treatment options. A retrospective review of all cholecystectomies performed over 15 years admitted to the surgical service at a single free-standing children's hospital was performed. Patient factors, indications for cholecystectomy, and final treatment were recorded. Complicated gallbladder disease was defined as having image-confirmed choledocholithiasis or gallstone pancreatitis. High-risk patients were those with imaging that demonstrated definitive choledocholithiasis or cholelithiasis with common bile duct enlargement. Low risk patients were those with cholelithiasis or gallbladder sludge on imaging combined with an elevated bilirubin and/or lipase. A total of 695 cholecystectomies were performed over the 15-year time period. Average patient age was 13.4 years. Of the 695 cholecystectomies, 457 were performed for stone disease (66%) (64 hemolytic) and 236 (34.0%) were performed for biliary dyskinesia. Hundred and three (14.8% of all cholecystectomies, 22.5% of those with stone disease) presented with choledocholithiasis and/or gallstone pancreatitis (complicated disease). In high-risk patients, 28/47 (59.6%) underwent endoscopic retrograde cholangiopancreatography/sphincterotomy. In low-risk patients (no choledocholithiasis or common duct enlargement), 13/56 (23.2%) required endoscopic retrograde cholangiopancreatography/sphincterotomy (P < .05). The indication for endoscopic retrograde cholangiopancreatography after cholecystectomy was choledocholithiasis and none of these patients had bile leak complications. The incidence of pediatric complicated biliary disease due to cholesterol stones is equal to that of adults. These data suggest that a patient with imaging evidence of choledocholithiasis or common bile duct enlargement may require endoscopic retrograde cholangiopancreatography, dependent on clinical course, and this should be strongly considered before cholecystectomy. Those without such radiographic findings can undergo laparoscopic cholecystectomy and have postoperative endoscopic retrograde cholangiopancreatography if needed.

Post-ERCP Dormia basket impaction: a case report and literature review

The incidence of Common bile duct stones (CBD) in patients undergoing cholecystectomy is 10%. The present-day management of common bile duct stone may be pre-, intra-, or post-operative Endoscopic retrograde cholangio-pancreatography (ERCP) with stone extraction. The reported complications of ERCP and CBD stone extraction range from 5 to 10% cases, that might be life threatening. Herein, we reported a case of calculus obstructive jaundice and cholangitis. Unfortunately, trials for ERCP and stone retrieval was followed by impacted Dormia basket which was successfully managed by surgerys.

Intervention versus surveillance in patients with common bile duct stones detected by intraoperative cholangiography: a population-based registry study.

Each year 13 000 patients undergo cholecystectomy in Sweden, and routine intraoperative cholangiography (IOC) is recommended to minimize bile duct injuries. The risk of requiring endoscopic retrograde cholangiopancreatography (ERCP) following cholecystectomy for common bile duct (CBD) stones where IOC is omitted and in patients with CBD stones left in situ is not well known. Data were retrieved from the population-based Swedish Registry of Gallstone Surgery and ERCP between 1 January 2009 and 10 December 2019. Primary outcome was risk for postoperative ERCP for retained CBD stones. A total of 134 419 patients that underwent cholecystectomy were included and 2691 (2.0 per cent) subsequently underwent ERCP for retained CBD stones. When adjusting for emergency or planned cholecystectomy, preoperative symptoms suggestive of CBD stones, sex and age, there was an increased risk for ERCP when IOC was not performed (hazard ratio (HR) 1.4, 95 per cent c.i. 1.3 to 1.6). The adjusted risk for ERCP was also increased if CBD stones identified by IOC were managed with surveillance (HR 5.5, 95 per cent c.i. 4.8 to 6.4). Even for asymptomatic small stones (less than 4 mm), the adjusted risk for ERCP was increased in the surveillance group compared with the intervention group (HR 3.5, 95 per cent c.i. 2.4 to 5.1). IOC plus an intervention to remove CBD stones identified during cholecystectomy was associated with reduced risk for retained stones and unplanned ERCP, even for the smallest asymptomatic CBD stones.

Choledocholithiasis-a new clinical pathway.

The incidence of cholecystectomy in children has increased considerably since the early 1990s. Management of gallbladder disease in children must include an awareness of choledocholithiasis treatment strategies. Both endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct exploration (open or laparoscopic) are accepted management techniques for choledocholithiasis. Laparoscopic cholecystectomy with preoperative or postoperative ERCP is at least a two-procedure process while cholecystectomy with laparoscopic common bile duct exploration (LCBDE) can provide definitive treatment in a single procedure under one anesthetic. Despite this, the trend over the last decade continues towards less LCBDE utilization in favor of ERCP. This trend has resulted in decreased familiarity with LCBDE by adult and pediatric surgeons and their trainees. Access to the necessary tools and education on the technical aspects can allow for successful single-stage treatment of choledocholithiasis by surgeons during laparoscopic cholecystectomy. This may include a pre-defined stepwise algorithm and understanding of all the equipment and resources necessary to perform a LCBDE. Ultimately, increased understanding of the equipment and procedural steps necessary for LCBDE will result in widened adoption of the technique and thus confer advantages to the patient such as decreased length of stay and fewer required anesthetics.

Factors Affecting the Choice of Treatment in Hepatic Hydatid Cyst Surgery

Objective We aimed to determine the effective factors in the selection of treatment methods for patients with hepatic hydatid cyst undergoing surgery and the variables effective when performing postoperative endoscopic retrograde cholangiopancreatography (ERCP). In addition, we aimed to reveal the factors affecting the recurrence, postoperative complications, and length of stay of these patients. Materials and methods A total of 107 patients diagnosed with hepatic hydatid cysts were treated surgically. Data were obtained from the records of these patients. Chi-square test was used for the analysis. The variables that were found to be significant in the chi-square analysis were included in the logistic regression (Backward: LR) analysis. Results Of all patients, 6.5% underwent the puncture, aspiration, injection, and reaspiration (PAIR) technique, 67.3% underwent conservative surgery, and 26.2% underwent radical surgical treatment. In paired comparisons, a significant difference was found among the ultrasonographic size of the cyst (p = 0.033), the radiological classification of the cyst (0.006), and history of previous surgery and treatment methods for the cyst. The risk of performing ERCP was 25.710 [95% confidence interval (CI): 1.721–284.013] folds higher for cysts located in the left lobe, whereas it was 19.992 (95% CI: 2.004–199.488) folds higher for cysts located in both right and left lobes. When the radical surgical treatment method was taken as a reference, the status of ERCP implementation was 29.785 (95% CI: 1.844–480.996) folds higher for PAIR and 3.628 (95% CI: 0.355–37.103) folds higher for conservative surgery. Conclusion In conclusion, radical surgery is a significant treatment for hepatic hydatid cyst as its ultrasonographic cyst size increases with time. The location and treatment method of the cyst increases the complication of biliary fistula and requires ERCP.

The effect of prolonged antibiotics on postoperative complications for common bile duct stones: A post hoc analysis of an EAST multicenter study.

Antimicrobial guidance for common bile duct (CBD) stones is limited. We sought to examine the effect of antibiotic duration on infectious complications in patients with choledocholithiasis and/or gallstone pancreatitis. We performed a post hoc analysis of a prospective, observational, multicenter study of patients undergoing same admission cholecystectomy for choledocholithiasis and gallstone pancreatitis between 2016 and 2019. We excluded patients with cholangitis and/or cholecystitis. Patients were divided into groups based on duration of antibiotics: prophylactic (<24 hours) or prolonged (≥24 hours). We analyzed these two groups in the preoperative and postoperative periods. Outcomes included infectious complications, acute kidney injury (AKI), and hospital length of stay (LOS). There were 755 patients in the cohort. Increasing age, CBD diameter, and a preoperative endoscopic retrograde cholangiopancreatography (odds ratio, 1.91; 95% confidence interval, 1.34-2.73; p < 0.001) significantly predicted prolonged preoperative antibiotic use. Increasing age, operative duration, and a postoperative endoscopic retrograde cholangiopancreatography (odds ratio, 4.8; 95% confidence interval, 1.85-13.65; p < 0.001) significantly predicted prolonged postoperative antibiotic use. Rates of infectious complications were similar between groups, but LOS was 2 days longer for patients receiving overall prolonged antibiotics (p < 0.0001). Patients with AKI received two more days of overall antibiotic therapy (p = 0.02) compared with those without AKI. Rates of postoperative infectious complications were similar among patients treated with a prolonged or prophylactic course of antibiotics. Prolonged antibiotic use was associated with a longer LOS and AKI. Therapeutic, Level IV.

Laparoscopic Management of Common Bile Duct Stones: Stratifying Risks, a District Hospital Experience.

Background: Management of bile duct stones is variable. Selection of the appropriate treatment modality based on identifiable risk factors can increase the chances of a successful outcome. The aim of this study is to identify factors affecting outcomes of a laparoscopic bile duct exploration. Methods: Retrospective data analysis of consecutive laparoscopic bile duct explorations over a period of 13 years at a district general hospital. Results: The total number of patients in the study was 85. Elective explorations were 56 while 29 were emergency procedures. The mean operative time was 154 minutes. The conversion rate was 14% with failure to extract stones being the most common reason. Forty-two percent of conversions were in nonelective procedures and 17% in previous endoscopic retrograde cholangiopancreatography (ERCP) failures. Eleven percent patients had a transcystic clearance of bile duct and the largest stone removed transcystic was 5 mm. The largest stone removed by a laparoscopic choledochotomy was 15 mm and stones >20 mm were removed on conversion. Seven patients (8%) had a postoperative bile leak, 4 of these required a postoperative ERCP stent and radiological drainage while 3 required a reoperation. Three patients had retained stones treated by postoperative ERCP. Conclusion: Emergency procedures, increasing number and size of stones, previous failed ERCP are factors that contribute to the outcomes of a laparoscopic bile duct exploration. The chances of a successful exploration can be improved by appropriate patient and procedure selection and preparation based on identification of these factors.

Comparison of Endoscopy First and Laparoscopic Cholecystectomy First Strategies for Patients With Gallstone Disease and Intermediate Risk of Choledocholithiasis: Protocol for a Clinical Randomized Controlled Trial.

BackgroundThe optimal approach for patients with gallbladder stones and intermediate risk of choledocholithiasis remains undetermined. The use of endoscopic retrograde cholangiopancreatography for diagnosis should be minimized as it carries considerable risk of postprocedural complications, and nowadays, less invasive and safer techniques are available.ObjectiveThis study compares the two management strategies of endoscopic ultrasound before laparoscopic cholecystectomy and intraoperative cholangiography for patients with symptomatic cholecystolithiasis and intermediate risk of choledocholithiasis.MethodsThis is a randomized, active-controlled, single-center clinical trial enrolling adult patients undergoing laparoscopic cholecystectomy for symptomatic gallbladder stones with intermediate risk of choledocholithiasis. The risk of choledocholithiasis is calculated using an original prognostic score (the Vilnius University Hospital Index). This index in a retrospective evaluation showed better prognostic performance than the score proposed by the American Society for Gastrointestinal Endoscopy in 2010. A total of 106 participants will be included and randomized into two groups. Evaluation of bile ducts using endoscopic ultrasound and endoscopic retrograde cholangiography on demand will be performed before laparoscopic cholecystectomy for one arm (“endoscopy first”). Intraoperative cholangiography during laparoscopic cholecystectomy and postoperative endoscopic retrograde cholangiopancreatography on demand will be performed in another arm (“cholecystectomy first”). Postoperative follow-up is 6 months. The primary endpoint is the length of hospital stay. The secondary endpoints are accuracy of the different management strategies, adverse events of the interventions, duct clearance and technical success of the interventions (intraoperative cholangiography, endoscopic ultrasound, and endoscopic retrograde cholangiography), and cost of treatment.ResultsThe trial protocol was approved by the Vilnius Regional Biomedical Research Ethics Committee in December 2017. Enrollment of patients was started in January 2018. As of June 2020, 66 patients have been enrolled.ConclusionsThis trial is planned to determine the superior strategy for patients with intermediate risk of common bile duct stones and to define a simple and safe algorithm for managing choledocholithiasis.Trial RegistrationClinicalTrials.gov NCT03658863; https://clinicaltrials.gov/ct2/show/NCT03658863.International Registered Report Identifier (IRRID)DERR1-10.2196/18837

Long Term Outcomes of Trans-Cystic Bile Duct Exploration

Introduction: Laparoscopic transcystic common bile duct exploration (LTCBDE) at the time of cholecystectomy for choledocholithasis negates the need for endoscopic retrograde cholangiopancreatography (ERCP), along with its associated complications and cost. The aim of this study was to assess the long-term outcomes associated with TCBDE. Methods: Patients undergoing LTCBDE at the Royal Brisbane Hospital between 1995 and 2019 were retrospectively analysed. LTCBDE was performed using a 5.5-Fr wire basket kit (Cook Australia) under fluoroscopic guidance. Satisfactory completion of the CBD exploration was confirmed by completion cholangiography. Patients had clinical follow up post discharge. Data were analysed using R statistics with a p< 0.05 considered significant. Results: 397 patients underwent LTCBDE, with 262 females. The median age was 52 years old (range 16-88). Median follow up was 5.4 years, and the median length of hospital stay was 1 day (range 0 - 28). 28 patients (7.1%) required postoperative ERCP for failure of complete stone clearance at LTCBDE. Two patients developed mild acute pancreatitis postoperatively after successful duct clearance. Four patients (1%) required ERCP following discharge post LTCBDE, after representing with symptomatic choledocholithiasis. Overall, 91.9% of patients had successful bile duct clearance with LTCBDE. Cost analysis comparing LTCBDE with the average cost of patients undergoing ERCP followed by laparoscopic cholecystectomy showed LTCBDE to be significantly less (p< 0.05). Conclusion: Upfront laparoscopic CBDE is now a well-established practice at this unit. This study reports a high rate of bile duct stone clearance with LTCBDE, with minimal complications and obvious cost benefits.

Balloon sphincteroplasty in pediatric laparoscopic common bile duct exploration

The management of choledocholithiasis in children and teenagers is often a two-procedure process with laparoscopic cholecystectomy (LC) and either pre- or post-operative endoscopic retrograde cholangiopancreatography (ERCP). The addition of laparoscopic common bile duct exploration (LCBDE) during LC can provide definitive treatment for choledocholithiasis during a single anesthetic event. In an effort to minimize sedation and radiation exposure from fluoroscopy, we have employed dilating balloons via a transcystic approach to stretch the sphincter of Oddi with subsequent ductal flushing. We describe the technique of balloon sphincteroplasty as a straightforward adjunct within the pediatric surgeon's skill set to manage choledocholithiasis during LC and our clinical experience.

Assessment of Laparoscopic Intraoperative Cholangiogram in Controlling Postoperative Outcomes and Its Implication on the Quality of Life

Background: Intraoperative cholangiography (IOC) is one of the surgical advances that aim to reduce the risk of bile duct injuries. Aim: To assess the role of IOC in controlling the postoperative outcomes and its implication on patient quality of life. Patients and Methods: This prospective randomized study conducted at the Department of Surgery, Faculty of Medicine, Suez Canal University from May 2017 to February 2019 on 56 patients with symptomatic gall stones who met our inclusion criteria. The exclusion criteria were having former upper abdominal surgery, chronic liver disease, impaired kidney function, bleeding tendency, and Common bile duct (CBD) stones indicated for preoperative ERCP. Our protocol was approved by the institutional review board at Suez Canal University. Results: Our sample comprised of 56 patients. The mean age was 42 ± 10 years, and most patients were females (68%). Most patients had no interventions like CBD explorations (82%). The success rate was 96%. Two patients had failed CBD exploration and referred to postoperative Endoscopic Retrograde Cholangiopancreatography (ERCP). Of notice, there were no reported cases of bile duct injury, and the mortality rate was 0%. Conclusion: IOC during laparoscopic cholecystectomy (LC) is associated with a low morbidity rate and no mortalities. This confirms the effectiveness of IOC in reducing the postoperative complications of LC which improve patent’s quality of life.

Role of intraoperative cholangiogram (IOC) in diagnosing residual stones and variable anatomy in laparoscopic cholecystectomy (LC)

Background: Incidence of common bile duct (CBD) stones on Intra-operative Cholangiogram (IOC) ranges from 8-15% and it causes complications in 15% of these patients. IOC has high sensitivity (97%) and specificity (99%) but routine use causes increasing costs and operating time. Studies have indicated that IOC is not indicated if preoperative liver enzymes are normal. We evaluated efficacy of IOC in diagnosing stones and abnormal anatomy. Materials and Methods: A retrospectively analysis was performed of patients undergoing LC from January 2018-June 2018. We investigated pre-operative liver function tests (LFTs), if patients underwent pre-operative endoscopic retrograde cholangiopancreatography (ERCP), Endoscopic ultrasound (EUS) or Magnetic resonance cholangiopancreatography (MRCP), IOC findings, post-op complications and need of post-operative interventions (ERCP). Results: This study included 55 females, 28 males. The median age was 52yrs. 5 patients had markedly raised serum bilirubin (>80μmol/L). They underwent MRCP or EUS followed by pre-operative ERCP. 6 Patients had borderline raised bilirubin (>25μmol/L) and 7 had raised ALP (>147 IU/L). None of these patients showed stones on IOC. The incidence of stone and abnormal anatomy (abnormal insertion of cystic duct) on IOC was 6.4% and 3.6% respectively. All patients with stones had normal LFTs. The Sensitivity of IOC for stone was 100%, Specificity was 88%, Positive Predictive Value was 50% and Negative Predictive Value was 100%. False positive rate was 6.4%. There were no complications from IOC or missed retained stones. Conclusion: IOC is often only performed in patients with mild deranged pre-operative LFTs. In our HPB department we routinely perform IOC in LC. Our incidence rate (6.4%) of stones in such patients indicates IOC has role in detecting coincidental stones. Performing post-operative ERCP during same admission potentially prevents complications. In addition, recognizing abnormal anatomy on IOC is useful for cautious dissection.