Preoperative Endoscopic Retrograde Cholangiography Research Articles

Is drip infusion cholecystocholangiography (DIC) an acceptable modality at cholecystectomy for cholecystolithiasis, considering the frequency of bile duct maljunction and intraoperative bile duct injury?

Knowledge of the configuration of the extrahepatic bile duct is indispensable to avoid bile duct injury during cholecystectomy. Various methods of examining the biliary tract have been developed; however, the most appropriate preoperative diagnostic modality at cholecystectomy for cholecystolithiasis has not yet been reported. Considering the frequency of bile duct maljunction (BDM) and operative bile duct injury, in addition to the cost and invasiveness of the various examination methods, we evaluated the usefulness of drip infusion cholecystocholangiography (DIC) as the optimal method of examination at cholecystectomy for cholecystolithiasis. Preoperative diagnostic accuracy of BDM was analyzed in relation to operative bile duct injury using 469 patients with benign biliary diseases who was diagnosed with DIC and endoscopic retrograde cholecystography and underwent cholecystectomy. BDM was classified according to Hisatsugu criteria. Out of 469 consecutive patients who underwent a cholecystectomy for biliary stones between January 1, 1995, and September 30, 1998, at Ohta Nishinouchi General Hospital, 21 (4.48%) had a cystic duct maljunction (CDM) and 12 (2.56%) had an aberrant bile duct (ABD). The most common variants were types C and D for CDM, and types II and III for ABD, according to Hisatsugu's classification. Fourteen patients (42.4%) were diagnosed before the surgery; 13 of them received preoperative endoscopic retrograde cholangiography (ERC), and the remaining patient underwent preoperative drip infusion cholecystocholangiography (DIC). Nineteen patients could not be correctly diagnosed based on their preoperative examinations, but were diagnosed during surgery. Operative bile duct injury occurred in 1 patient (0.2%) whose maljunction could not be diagnosed before the operation. Taking into account the medical cost and invasiveness, and the frequency of BDM and related bile duct injuries, we conclude that DIC is an acceptable preoperative diagnostic modality to employ at cholecystectomy for cholecystolithiasis. Knowledge of the configuration of the extrahepatic bile duct is indispensable to avoid bile duct injury during cholecystectomy. Various methods of examining the biliary tract have been developed; however, the most appropriate preoperative diagnostic modality at cholecystectomy for cholecystolithiasis has not yet been reported. Considering the frequency of bile duct maljunction (BDM) and operative bile duct injury, in addition to the cost and invasiveness of the various examination methods, we evaluated the usefulness of drip infusion cholecystocholangiography (DIC) as the optimal method of examination at cholecystectomy for cholecystolithiasis.

Pre-operative endoscopic ultrasonography can optimise the management of patients undergoing laparoscopic cholecystectomy with abnormal liver function tests as the sole risk factor for choledocholithiasis: a prospective study

Background. Pre-operative endosonography has been proposed as a cost-effective procedure in the management of patients who undergo laparoscopic cholecystectomy having an intermediate risk of common bile duct stones. We prospectively evaluated the impact of pre-operative endosonography on the management of patients facing laparoscopic cholecystectomy with abnormal liver function tests as the sole risk factor for choledocolithiasis. Methods. Among 587 consecutive patients scheduled for laparoscopic cholecystectomy, 47 (8%) patients having one or more abnormal liver function tests but a normal appearance of common bile duct at abdominal ultrasound, underwent pre-operative endosonography. In patients with endosonography-detected common bile duct stones, a pre-operative endoscopic retrograde cholangiography was performed, or an intra-operative endoscopic retrograde cholangiography was scheduled. In all endosonography-negative patients, an intra-operative trans-cystic cholangiography was performed. Results. Endosonography detected common bile duct stones in nine patients (19%) but only in five of them stones were radiologically confirmed (PPV 0.55). Endosonography-detected stones were confirmed in four of four (100%) patients in whom cholangiography was performed within 1 week, but only in one of five (20%) patients in whom radiology was further delayed ( P<0.05). In three of four cases (75%), stones detected at endosonography but not confirmed at X-rays, were smaller than 2.0 mm. Among 38 patients with negative endosonography, common bile duct stones were found in two patients (NPV 0.95), whereas unplanned endoscopic stone extraction was needed only in one patient (NPV 0.97). Conclusions. Pre-operative endosonography can spare unnecessary pre-operative endoscopic retrograde cholangiography as well as inappropriate scheduling of intra-operative endoscopic retrograde cholangiography in patients undergoing laparoscopic cholecystectomy with abnormal liver function tests. To maximise the impact of endosonography on the management of these patients, the procedure should be performed immediately before laparoscopic cholecystectomy.

Selective cholangiography in 600 patients undergoing cholecystectomy with 5-year follow-up for residual bile duct stones

The need for cholangiography to identify possible bile duct stones in all patients undergoing cholecystectomy is controversial. To assess the results of a policy for selective pre-operative endoscopic retrograde cholangiography (ERC) in patients undergoing laparoscopic cholecystectomy and to determine the incidence of postoperative symptomatic bile duct stones. Between 1993 and 1998, 600 patients underwent laparoscopic cholecystectomy under one consultant surgeon. Patients were selected for pre-operative or postoperative ERC based on symptoms, liver function tests and/or abnormalities on ultrasonography. A general practitioner questionnaire was used to assess follow-up of patients with postoperative stones. Of 600 patients, 107 (18%) with a median age of 57 years and male:female ratio of 1:2.1 were selected to undergo pre-operative ERC; of these, 41 patients (38%) had bile duct stones. Postoperative ERC was performed in 30 patients (5%) and stones were identified in seven (23.3%). Three patients (0.5%) had stones removed within 15 days of operation and four (0.7%) between 2.6 months and 1.8 years. Median follow-up was 5.0 years (range, 2.5-7.5 years). The overall incidence of bile duct stones was 48 cases (8%). The stone rate was 11% in males and 7.3% in females. Stones were successfully extracted at ERC in 43 patients (89.6%). A policy of selective pre-operative ERC is the most effective technique for identifying and removing bile duct stones and the incidence of symptomatic gallstones following laparoscopic cholecystectomy is very low. With an overall stone rate of 8%, routine peroperative cholangiography is unnecessary and, in a surgical unit providing an ERC service, laparoscopic exploration of the bile duct is not a technique required for the management of bile duct stones.

Endoscopic sphincterotomy prior to laparoscopic cholecystectomy for the treatment of cholelithiasis.

We performed this study to assess the outcome of endoscopic retrograde cholangiography (ERC) before laparoscopic cholecystectomy (LC) for symptomatic gallbladder and suspected duct stones. We performed prospective study of 310 patients with symptomatic gallstones and suspected choledocholithiasis managed by preoperative ERC with endoscopic extraction (ESE) and LC. The presence of one or more of the following criteria at hospital admission led to preoperative ERC because of suspected choledocholithiasis: jaundice for more than 72 h, ultrasonography measurement of the common bile duct > 8 mm, cholestasis, and acute biliary pancreatitis. ERC for suspected choledocholithiasis was performed in 310 patients. The rate of successful cannulation for ERC was 96.8%. Duct stones were found in 86%. Twelve patients had impacted duct stones cleared at open common duct exploration. The failure rate of ERC was 4.5%, and the rate of unnecessary ERC was 13.5%. LC was performed in 298 of 310 patients. Morbidity rates were 2.2% and 1.5% after ESE and LC, respectively. A total of 95.5% of patients with symptomatic gallbladder and ductal stones could be successfully managed by ERC prior to LC with a low morbidity rate.

Preoperative endoscopic sphincterotomy and laparoscopic cholecystectomy for the management of cholecystocholedocholithiasis: 10-year experience.

No procedure has yet been identified as the "gold standard" for the detection and treatment of common bile duct stones (CBDS) in patients undergoing laparoscopic cholecystectomy (LC). This prospective study involves 2137 patients undergoing elective laparoscopic cholecystectomy. The algorithm for diagnostic management in place until July 1997 involved routine intravenous cholangiography and selective endoscopic retrograde cholangiography (ERC). Subsequently, assessment of the bile duct was not routinely performed, but a scoring system was applied to single out those patients at risk of CBDS who should undergo intravenous cholangiography and/or ERC (see Fig. 2). Whenever bile duct stones were found, endoscopic sphincterotomy (ES) was performed, and LC was performed with a standardized four-cannula technique after endoscopic bile duct stone clearance. Common bile duct stones were suspected in 340 patients who were referred for preoperative ERC; 250 patients were referred for ES; 21 patients were referred for open surgery because of failure of ERC or sphincterotomy. Common bile duct stones, detected in 283 cases (13.2%), were removed before surgery in 250 cases (88.3%) and during surgery in 28 cases (9.9%). Self-limited pancreatitis occurred in 4.2% of the patients after sphincterotomy. Laparoscopic cholecystectomy was performed in 98.4% of the cases. The conversion rate was 8.3% if sphincterotomy had been performed previously and 3.4% after standard laparoscopic cholecystectomy (p < 0.001). The morbidity rate was 4.5%; mortality, 0.09%. During follow-up five patients (0.2%) had retained stones endoscopically treated. Future trials of novel strategies for detecting and treating CBDS should compare the results of novel strategies with those of the strategy employed in this study, which includes selective ERC, preoperative ES, and LC.

An unusual cause of delayed presentation of laparoscopic common bile duct injury

We describe an unusual case of a laparoscopic common bile duct (CBD) injury that presented with cholangitis 2 years after an apparently uneventful laparoscopic cholecystectomy. Preoperative ultrasound and endoscopic retrograde cholangiography suggested choledocholithiasis, showing proximal and intrahepatic duct dilatation with an inability to relieve the obstruction. At surgery, a lateral injury of the CBD wall with partial wall loss was found, adherent to an amorphous pigmented mass with the appearance of a knitted fabric causing CBD obstruction. The CBD was successfully reconstructed with a Roux-en-Y end-to-side hepaticojejunostomy, where the end of the Roux loop was anastomosed to the lateral CBD defect.

Stellenwert der Magnetresonanz-Cholangiographie in der rationellen Diagnostik der Choledocholithiasis

Management of symptomatic cholecystolithiasis is vitally influenced by dilated biliary tract and choledocholithiasis. The objectives of this prospective pilot study were to evaluate the diagnostic value of preoperative magnetic resonance cholangiography (MRC) compared to diagnostic endoscopic retrograde cholangiography (ERC) and to establish an efficient algorithm for diagnostics and treatment of choledocholithiasis. All consecutive patients with cholecystolithiasis and dilated biliary tract proven by sonography as well as elevated liver function tests were enrolled within 12 months. Patients without evidence of bile duct calculi underwent preoperative MRC, whereas patients with choledocholithiasis immediate ERC. 58 patients (30 male, 28 female) with a median age of 59.4 years underwent preoperative MRC. In 18 patients (10 male, 8 female; median age 63.5 years) with evidence of choledocholithiasis we subsequently performed ERC and papillotomy. Bile duct stones were detected and removed after papillotomy in 10 patients, whereas calculi could not be found anymore in 8 patients. The remaining 40 patients without calculi evident on MRC were transferred to magnetic resonance tomography and ERC in case of suspected malignancy or to cholecystectomy and intraoperative cholangiography (IOC), which could definitely exclude choledocholithiasis. In comparison to ERC respectively IOC, MRC was able to detect bile duct stones with a sensitivity of 100% and a specificity of 83.3%. Non-invasive MRC seems to replace diagnostic ERC concerning the presence of choledocholithiasis in case of cholecystolithiasis and dilated biliary tract with a high sensitivity. The preoperative ERC with stone extraction is still the therapy of choice in case of radiologically confirmed choledocholithiasis.

Intraoperative cholangiography is still indicated after preoperative endoscopic cholangiography for gallstone disease.

Intraoperative cholangiography (IOC) is frequently omitted in patients undergoing laparoscopic cholecystectomy (LC) if they have had successful preoperative endoscopic retrograde cholangiography (ERC). A prospectively maintained divisional laparoscopic cholecystectomy database was searched from 1991 to 1997 for patients who had IOC after preoperative ERC. The presence of recurrent or residual common duct stones seen on IOC and their impact on subsequent management were evaluated. We identified a group of 127 patients who underwent preoperative ERC. Thirty-one patients (31/127, or 24%) went on to receive an IOC during cholecystectomy. In 15 patients whose preoperative ERC was reported normal, five (33%) had an abnormal IOC. In 16 patients whose ERC was reported as having cleared the duct, eight (50%) had an IOC abnormality. Eight of these 31 patients required a further procedure to clear the duct. Retained or recurrent common duct stones at cholecystectomy following diagnostic or therapeutic ERC were more common than expected. Therefore, IOC is recommended during LC regardless of the findings yielded by the preoperative ERC.

Laparoendoscopic approach to treatment of common bile duct stones.

Whereas laparoscopic cholecystectomy represents the gold standard treatment for gallstones, there is no universal consensus on the optimal treatment of common bile duct (CBD) stones. The options available are various: preoperative or postoperative endoscopic retrograde cholangiography and sphincterotomy, laparoscopic transcystic CBD exploration, laparoscopic choledochotomy, and traditional open choledochotomy. A few reports describe intraoperative endoscopic clearance of the CBD. The choice of one of these methods depends on the timing of the detection of CBD stones with regard to the cholecystectomy, the expertise of the surgeon, the technology available, and the wishes of the patient. In the surgical department of the "Ospedale Casa Sollievo della Sofferenza," a large referral medical center in Italy, we perform an intraoperative endoscopic sphincterotomy in the presence of findings suspicious for CBD stones in the course of a laparoscopic cholecystectomy. The procedure is readily available thanks to the nearby presence of a skilled endoscopist and is greatly aided by the insertion of a transcystic guidewire, which makes the papilla easily identifiable by the endoscope for the spincterotomy. We have used the technique successfully in 43 of 45 patients over a 7-year period in an overall caseload of 1775 laparoscopic cholecystectomies, with no complications, minimal added operative time, and no added postoperative hospital stay. The technique allows us to completely and definitively manage CBD stones detected intraoperatively at the time of the performance of the laparoscopic cholecystectomy with no added discomfort to the patient.

Laparoscopic common bile duct exploration: the past, the present, and the future

Background: The advent of laparoscopic cholecystectomy (LC) has created a dilemma for treating patients with known or suspected choledocholithiasis. With rapid technologic growth and experience in laparoscopic skills, many surgeons are now routinely performing laparoscopic common bile duct exploration (LCBDE) and questioning the wisdom of preoperative endoscopic retrograde cholangiography (ERC) with or without endoscopic sphincterotomy. The purpose of this article is to review the current literature on the subject of LCBDE and critically evaluate the clinical results of this emerging technology. Methods: Medline and Science Citation Index databases were used to search English language articles published on LCBDE since 1989. Results: Transcystic common bile duct exploration has a better clearance rate, and carries less morbidity and mortality compared with laparoscopic choledochotomy. Compared with two-stage ERCP and LC, one-stage LC and LCBDE seems to be associated with a shorter hospital stay, a quicker recovery, less expense, and less morbidity and mortality. Conclusions: LCBDE is a feasible, safe and effective procedure that carries a low morbidity and mortality and will decrease the need for unnecessary ERC in the future for suspected or proved choledocholithiasis.

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.

Evaluation of Magnetic Resonance Cholangiography in the Management of Bile Duct Stones

Magnetic resonance cholangiography (MRC) offers the potential for accurate, noninvasive detection of common bile duct stones (CBDSs) before cholecystectomy, and for a consequent reduction in the incidence of preoperative negative diagnoses associated with endoscopic retrograde cholangiography (ERC). Prospective cohort study: MRC results were correlated with ERC (high-risk patients) or intraoperative cholangiography (moderate-risk patients). A university hospital providing primary, secondary, and tertiary care. Seventy patients with suspected CBDSs scheduled to undergo elective cholecystectomy between April 15, 1997, and September 30, 1998. Forty patients were considered at high risk and 30 at moderate risk for CBDSs, according to results of liver function tests and sonograms of the upper abdomen. Confirmation or exclusion of CBDSs by MRC was assessed by a panel of radiologists who were unaware of the ERC results. Results of ERC and intraoperative cholangiography were analyzed by the investigating gastroenterologists or surgeon. Results of MRC were positive for CBDSs in 21 (52%) of 40 high-risk patients, a finding confirmed by preoperative ERC in 19 (90%) of 21 patients. Results of MRC were positive for CBDSs in 6 (20%) of 30 moderate-risk patients, all of which were confirmed by intraoperative cholangiography. Finally, CBDSs were present in 19 (48%) of 40 high-risk patients and 6 (20%) of 30 moderate-risk patients (P = .02). Overall sensitivity and specificity of MRC were 100% and 95.6%, respectively; the positive and negative predictive values were 92.6% and 100%, respectively. Magnetic resonance cholangiography is a reliable, noninvasive method for the detection or exclusion of CBDSs, and seems to reduce the frequency of negative diagnoses associated with ERC. Magnetic resonance cholangiography revealed no CBDSs in 19 (48%) of 40 patients at high risk for CBDSs. Thus, MRC-based diagnosis has the potential to reduce the number of invasive preoperative diagnostic procedures and their associated risks and overall health care costs.

Results of routine intraoperative cholangiography in laparoscopic cholecystectomy

Background The use of intraoperative cholangiography (IOC) has proved controversial in both open and laparoscopic cholecystectomy (LC). Our aim was to evaluate the use of routine IOC during laparoscopic cholecystectomy over a 3-year period. Methods Laparoscopic cholecystectomy was performed in 450 patients. Preoperative endoscopic retrograde cholangiography (ERCP) was performed in 14 patients, in whom stones were removed. IOC was attempted in 436 patients and was successfully performed in 394 of these (90%). Results In 18 patients (4.6%), IOC detected bile-duct stones, in two patients a cholecystoduodenal fistula and in one a partial section of the bile duct. The cystic duct was torn in one patient. IOC gave one false-positive and one false-negative result. Conclusions In laparoscopic surgery IOC should be mandatory. It is a safe procedure that is useful to detect stones in the bile duct and to recognise bile-duct injuries during the operation.

Routine intravenous cholangiography, selective ERCP, and endoscopic treatment of bile duct stones before laparoscopic cholecystectomy

Background: No procedure has yet been identified as the standard for the detection and management of choledocholithiasis in patients undergoing laparoscopic cholecystectomy. Methods: A prospective study involved 1305 patients undergoing elective laparoscopic cholecystectomy. Intravenous cholangiography was performed on all patients except those with jaundice or cholangitis, acute pancreatitis, or allergy to contrast material. Patients underwent endoscopic retrograde cholangiography (ERC) and endoscopic sphincterotomy when there was a strong suspicion of choledocholithiasis, positive or inconclusive findings on intravenous cholangiography or allergy to contrast material with signs of possible choledocholithiasis. Intraoperative cholangiography was performed when patients did not undergo ERC or intravenous cholangiography and whenever the surgeon was in doubt about biliary anatomy or biliary clearance. Results: Two hundred thirty-one patients (17.7%) were referred for preoperative ERC; 14 of them were referred for open surgery because of failure of ERC or sphincterotomy. Only 54 patients underwent intraoperative cholangiography. Bile duct stones, detected in 186 cases (14.2%) (68 of which were asymptomatic), were removed before surgery in 162 cases (87.1%) and during surgery in 20 (10.7%). Self-limited pancreatitis occurred in 3.6% of the patients after sphincterotomy. Laparoscopic cholecystectomy was performed in 98.7% of the cases. The conversion rate was 8% if sphincterotomy had been performed previously, and 3% after standard laparoscopic cholecystectomy (p < 0.001). The morbidity rate was 5% and the mortality rate 0.08%. During the follow-up period 4 patients had retained stones that were treated endoscopically. Conclusions: Preoperative ERC followed by laparoscopy is the best approach to treatment of patients with cholecystolithiasis and suspected choledocholithiasis. (Gastrointest Endosc 1999;50:200-8.)

Proposed criteria for preoperative endoscopic retrograde cholangiography in candidates for laparoscopic cholecystectomy.

There has been a dramatic increase in the number of endoscopic retrograde cholangiograms (ERC) performed on patients who are candidates for laparoscopic cholecystectomy (LC). The majority of these procedures result in normal findings. This study is an attempt to determine useful clinical criteria and strategy for predicting the presence or absence of common bile duct stones (CBDS) and the need for ERC in patients who are candidates for LC. The observational portion of this study explored laboratory and ultrasound data from 134 consecutive patients who had undergone preoperative ERC, followed by LC, over a 4-year period. The data were then analyzed by multivariate logistic regression to determine the best models for predicting the presence or absence of stones in the common bile duct. Models using gamma glutamyl transpeptidase (GGT), alkaline phophatase (AP), common bile duct diameter (CBDIA), and amylase (AMY) were then evaluated retrospectively in 36 additional patients (validation group). A model based on GGT and common bile duct diameter as positive predictors and amylase as a negative predictor correctly classified 78% of the patients in the validation group. This model resulted in a negative predictive value (NPV), positive predictive value (PPV), sensitivity, and specificity of 0.88, 0.68, 0.87, and 0.71, respectively. The model utilizing AP was almost as effective. This model resulted in a NPV, PPV, sensitivity, and specificity of 0.83, 0.67, 0.80, and 0.71, respectively. Although a number of laboratory values and imaging techniques correlate with the presence or absence of CBDS, our study confirms that individually they have poor predictive value. Our data and models suggest that elevated serum amylase is a negative predictor for CBDS. Elevated GGT and/or AP with widened CBDIA and normal AMY strongly suggest the presence of CBDS and the need for preoperative ERC. Elevated GGT, AP, or widened CBDIA with elevated amylase, in the absence of clinical pancreatitis, may suggest that small stones have passed through the ampulla of Vater and that the CBD is generally cleared of stones.

Selection criteria for pre-operative endoscopic retrograde cholangiography and endoscopic-laparoscopic treatment of biliary stones.

Pre-operative endoscopic retrograde cholangiography (ERCP) prior to laparoscopic cholecystectomy (LC) is the most common treatment of gallbladder and common bile duct (CBD) stones. In this study we evaluate our selection criteria for pre-operative ERCP and the results of endoscopic-laparoscopic treatment in patients with CBD stones. Consecutive adult patients admitted to the department of surgery because of symptomatic cholelithiasis were included in a prospective open trial. Between January 1996 and December 1996, 841 patients underwent LC at our hospital. ERCP pre-LC was performed in 95 of the 841 patients, on the basis of our selection criteria. The indication to perform ERCP was suggested by a dilatated CBD (> 10 mm) or ductal stones, abnormal serum liver tests, persisting for more than 3 days, jaundice, cholangitis or pancreatitis. Twelve months after surgery, all patients were contacted by telephone to exclude symptoms related to residual stones. Cannulation of the CBD was successful in 94 of 95 patients submitted to pre-LC ERCP. CBD stones were found in 87 patients (95.6%) in 22 of whom (25.2%) they were in the form of small stones or sludge. In only three of 94 patients (3.2%) no alterations of the CBD or papilla were found. Complications occurred in eight of 98 patients (in five after endoscopic sphincterotomy (ES), and in three after LC). Pre-operative ES in selected patients with coexisting gallbladder and CBD stones has been a good approach and the criteria that we used for selection of patients to be submitted to pre-operative ERCP/ES seem to be effective.

Randomised trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde cholangiography for common bile duct stones

The management of stones in the common bile duct in the laparoscopic era is controversial. The three major options are preoperative endoscopic retrograde cholangiography (ERCP), laparoscopic exploration of the common bile duct (LECBD), or postoperative ERCP. Between August, 1995, and August, 1997, 471 laparoscopic cholecystectomies were done in our department. In 427 (91%), satisfactory peroperative cholangiography was obtained. In 80 (17%) of these cases there were stones in the common bile duct, 40 patients were randomised to LECBD and 40 to postoperative ERCP. If LECBD failed, patients had either open exploration of the common bile duct or postoperative ERCP. If one postoperative ERCP failed, the procedure was repeated until the common bile duct was cleared of stones or an endoprosthesis was placed to prevent stone impaction. The primary endpoints were duct-clearance rates, morbidity, operating time, and hospital stay. Analyses were by intention to treat. Age and sex distribution of patients was similar in the randomised groups. Duct clearance after the first intervention was 75% in both groups. By the end of treatment, duct clearance was 100% in the laparoscopic group compared with 93% in the ERCP group. Duration of treatment was a median of 90 min (range 25-310) in the laparoscopic group (including ERCPs for failed LECBD) compared with 105 min (range 60-255) in the postoperative ERCP group (p = 0.1, 95% CI for difference -5 to 40). Hospital stay was a median of 1 day (range 1-26) in the laparoscopic group compared with 3.5 days (range 1-11) in the ERCP group (p = 0.0001, 95% CI 1-2). LECBD is as effective as ERCP in clearing the common bile duct of stones. There is a non-significant trend to shorter time in the operating theatre and a significantly shorter hospital stay in patients treated by LECBD.

Randomised trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis

Laparoscopic cholecystectomy (LC) has become the treatment of choice for elective cholecystectomy, but controversy persists over use of this approach in the treatment of acute cholecystitis. We undertook a randomised comparison of the safety and outcome of LC and open cholecystectomy (OC) in patients with acute cholecystitis. 63 of 68 consecutive patients who met criteria for acute cholecystitis were randomly assigned OC (31 patients) or LC (32 patients). The primary endpoints were hospital mortality and morbidity, length of hospital stay, and length of sick leave from work. Analysis was by intention to treat. Suspected bile-duct stones were investigated by preoperative endoscopic retrograde cholangiography (LC group) or intraoperative cholangiography (OC group). The two randomised groups were similar in demographic, physical, and clinical characteristics. 48% of the patients in the OC group and 59% in the LC group were older than 60 years. 13 patients in each group had gangrene or empyema, and one in each group had perforation of the gallbladder causing diffuse peritonitis. Five (16%) patients in the LC group required conversion to OC, in most because severe inflammation distorted the anatomy of Calot's triangle. There were no deaths or bile-duct lesions in either group, but the postoperative complication rate was significantly (p=0.0048) higher in the OC than in the LC group: seven (23%) patients had major and six (19%) minor complications after OC, whereas only one (3%) minor complication occurred after LC. The postoperative hospital stay was significantly shorter in the LC than the OC group (median 4 [IQR 2-5] vs 6 [5-8] days; p=0.0063). Mean length of sick leave was shorter in the LC group (13.9 vs 30.1 days; 95% CI for difference 10.9-21.7). Even though LC for acute and gangrenous cholecystitis is technically demanding, in experienced hands it is safe and effective. It does not increase the mortality rate, and the morbidity rate seems to be even lower than that in OC. However, a moderately high conversion rate must be accepted.

The evolving role of endoscopic retrograde cholangiography before and after cholecystectomy.

Laparoscopy is the preferred approach for cholecystectomy; however the indications for pre- versus postoperative endoscopic retrograde cholangiography (ERC) are still evolving. The records of patients who had ERC performed one month before (n = 119) or after (n = 35) laparoscopic or open cholecystectomy from January 1990 to August 1992 (period 1), and 66 patients who had preoperative ERC from November 1995 to October 1996 (period 2) are reviewed, ERC indications, findings and outcomes were reviewed, and trends in the use of preoperative ERC from 1990 to 1996 were sought. Between periods 1 and 2 the yield of preoperative ERC increased from 36% to 58% (P < 0.01). The use of preoperative ERC for the indication of abnormal liver enzymes declined (P < 0.05), while the yield increased (25% versus 61%, P < 0.01). Both the use of ERC and the yield remained stable for other indications. ERC was felt to have changed the surgical approach in 5% of patients. Primary indications for postoperative ERC (n = 35) included abnormal intraoperative cholangiography (43%), liver function test abnormalities (23%) and recurrence of preoperative symptoms (14%); stones were found in 60%, 50% and 20% of patients with these indications, respectively. Overall, 46% of postoperative studies revealed duct stones. The roles for pre- and postoperative ERC are changing and depend greatly on the relative laparoscopic and endoscopic expertise at a given institution.

The Safety of Laparoscopic Cholecystectomy in Sickle Cell Disease: An Update

As surgery in sickle cell patients is associated with high morbidity, this study aims to establish the safety of minimally invasive surgery in this high-risk group. Over a four-year period, 71 sickle cell patients underwent laparoscopic cholecystectomy (LC) for cholelithiasis. Five patients had asymptomatic gallstones. Preoperative gastroscopy and endoscopic retrograde cholangiography were performed in 7 and 14 patients, respectively. Forty-two patients were given simple blood transfusions, while 13 received partial exchange transfusions. The mean operative time was 80 minutes and the conversion rate was 5.6%. There were 10 (14%) postoperative complications, the majority of which were respiratory and wound-related. One patient (1.4%) died as a result of postoperative vaso-occlusive crisis. The median hospital stay was 2.5 days. We believe that laparoscopic cholecystectomy is safe in patients with sickle cell hemoglobinopathy who are particularly at risk of developing pigmented gallstones. Therefore, the use of minimally invasive surgery is encouraged in any sickle cell patient undergoing operative intervention.