Preoperative Endoscopic Retrograde Cholangiopancreatography Research Articles

Laparoscopic Transduodenal Sphincteroplasty

Common bile duct stones are a difficult problem, often leading to conversion to an open operation or repeated endoscopic procedures. Both strategies are associated with added morbidity. A new technique was developed to perform a traditional sphincteroplasty using minimally invasive methods. The procedure was performed on two patients with distal common bile duct stones; each patient had previously undergone at least two unsuccessful preoperative endoscopic retrograde cholangiopancreatography procedures by at least two different experienced endoscopists. In both patients, a laparoscopic transduodenal sphincteroplasty was successfully completed. A transduodenal common bile duct exploration was performed at the time of sphincterotomy, successfully clearing the common bile duct in both cases. There were no untoward postoperative sequelae. Follow-up at one year was satisfactory in both patients. Laparoscopic transduodenal sphincteroplasty can be safely performed in patients with common bile duct stones refractory to endoscopic retrograde cholangiopancreatography. This technique offers a new approach to the management of common bile duct stones, and can spare patients the need for an open operation or subsequent endoscopic procedures.

Two-stage treatment with preoperative endoscopic retrograde cholangiopancreatography (ERCP) compared with single-stage treatment with intraoperative ERCP for patients with symptomatic cholelithiasis with possible choledocholithiasis

An ideal treatment for choledocholithiasis in the laparoscopic era has not been established. The objective of this study was to elucidate whether a treatment strategy of performing intraoperative endoscopic retrograde cholangiopancreatography (ERCP) during laparascopic cholecystectomy (when choledocholithiasis is confirmed by intraoperative cholangiography) is better for patients with suspected common bile duct stones than the current strategy (preoperative ERCP followed by laparoscopic cholecystectomy). This was a prospective randomized study to evaluate which of these two approaches was most benefit- and cost-effective for patients with intermediate risk of choledocholithiasis. Patients underwent either preoperative ERCP followed by a laparoscopic cholecystectomy a few weeks later (the "preoperative ERCP" group) or intraoperative ERCP (the "intraoperative ERCP" group). Intraoperative ERCP was performed using the rendezvous technique. There were 64 patients in the preoperative ERCP group and 59 patients in the intraoperative ERCP group. The demographic and clinical characteristics of the two groups were similar, except that the bilirubin and gamma-glutamyl transferase (GGT) levels and the number of patients treated on an inpatient basis were higher in the preoperative ERCP group. Success rates were similar (96.6 % in the preoperative ERCP group vs. 90.2 % in the intraoperative ERCP group in the per-protocol study). Total morbidity, post-ERCP morbidity, and post-ERCP acute pancreatitis rates were higher in the preoperative ERCP group, but there were no differences between the two groups in the frequency of residual common bile duct stones, the conversion rate to open cholecystectomy, or surgical morbidity. The length of hospital stay and costs were lower in the intraoperative ERCP group despite the longer surgical times in this group. Univariate analysis did not find any relationship between morbidity and total bilirubin or GGT. Logistic regression analysis confirmed that morbidity was related only to the treatment group and the time spent in the operating room: the relative risk (RR) was 4.37 for morbidity and 1.015 for the time spent in the operating room); the RR for papillotomy was 5.49. Both treatment approaches were equally effective but the intraoperative ERCP group had less morbidity, a shorter hospital stay, and reduced costs. The lower morbidity in the intraoperative ERCP group resulted from the lower rate of papillotomy and lower rates of post-ERCP pancreatitis and cholecystitis. Total morbidity was principally related to the type of treatment approach used.

Gallstone Pancreatitis – Who Really Needs an ERCP?

Gallstone Pancreatitis – Who Really Needs an ERCP?

Role of intraoperative cholangiography in laparoscopic cholecystectomy.

The results of a policy of selective cholangiography were assessed in 400 patients undergoing laparoscopic cholecystectomy. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) was performed in 81 patients (20 per cent) of whom 31 (38 per cent) showed definite or possible evidence of stones in the bile duct. Seventeen of the 400 patients underwent intraoperative cholangiography and the majority of these (12) were normal. After a minimum follow-up of 1 year, 17 patients (4 per cent) have had ERCP for suspected residual duct stones. Eight (2 per cent) of these revealed stones and all were successfully treated with sphincterotomy and duct clearance. Preoperative and postoperative ERCP was not associated with mortality or major morbidity. No major duct injury occurred and none was diagnosed within 2 years of operation. Routine intraoperative cholangiography is not a necessary part of laparoscopic cholecystectomy in the presence of an efficient and safe ERCP service.

Selective preoperative endoscopic retrograde cholangiopancreatography in laparoscopic biliary surgery.

The management of common bile duct (CBD) stones in patients subjected to laparoscopic cholecystectomy is still a subject of debate. A prospective study was performed of all 699 patients with symptomatic gallstones at risk of CBD stones between mid-1987 and 1994. Based on clinical, biochemical and ultrasonographic criteria, 119 patients underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP) with or without endoscopic sphincterotomy. Results showed a high positive predictive value (over 85 per cent) for the presence of CBD stones in patients with acute cholangitis, persistent obstructive jaundice or in the acute phase of gallstone pancreatitis. In the other groups (increased liver enzyme levels, a wide CBD and after resolution of jaundice or pancreatitis) the positive predictive value was less than 25 per cent. The complication rate of ERCP with sphincterotomy was 14 per cent with a mortality rate of 2 per cent. These results argue for more selective use of preoperative ERCP only for patients with acute cholangitis, persistent jaundice or acute gallstone pancreatitis. Other patients at risk of harbouring CBD stones should undergo intraoperative laparoscopic cholangiography and, if stones are found, laparoscopic exploration of the bile duct or postoperative ERCP.

Laparoscopic approach as primary treatment of common bile duct stones in children

Background Preoperative endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy (ES) are an effective strategy for choledocholithiasis, but complications such as pancreatitis and outcome in children are unknown. The laparoscopic cholecystectomy became the new gold standard in children for cholelithiasis. For the choledocholithiasis in children, the attitude is more controversial. We analyzed our series of laparoscopic approach for the management of choledocholithiasis in children to determine if it is an effective procedure. Patients and Method Between 1996 and 2001, 126 children were treated for cholelithiasis in our institution; 13 children (10.3%) were managed for a choledocholithiasis. We reviewed age at symptom onset results of paraclinical examinations, the type of laparoscopic management, and postoperative outcome. Results The mean age at clinical signs was 9.9 years (range, 3 months–15.5 years). One child was excluded because he had a preoperative ES. Twelve children had a laparoscopic cholecystectomy and cholangiogram at the same time. A choledocholithiasis was found in 10 cases. A flush of the common bile duct (CBD) was performed in all cases with a 3F or 5F ureteral catheter; the stone was pushed into the duodenum in 3 cases and successfully extracted in 3 with a 4F Dormia or Fogarty catheter. One child needed a conversion to open surgery. Three times, an ES was necessary in postoperative course in each case for clinical and biologic signs of CBD obstruction or pancreatitis (30%). All children are symptom-free with an average follow-up of 28 months. Conclusion Laparoscopic CBD exploration for choledocholithiasis can be performed safely in children at the time of cholecystectomy and can clear all of the stones in the CBD in two thirds of cases. If there is residual obstruction, a postoperative ES can be performed. We suggest primary treatment of choledocholithiasis by laparoscopic approach in children.

Early versus Delayed Single-Stage Laparoscopic Eradication for Both Gallstones and Common Bile Duct Stones in Mild Acute Biliary Pancreatitis

Several studies addressed that preoperative endoscopic retrograde cholangiopancreatography (ERCP) for common bile duct (CBD) clearance, followed by interval laparoscopic cholecystectomy (two-stage approach), constitutes the most common practice in cases of uncomplicated mild acute biliary pancreatitis. Between June 1998 and December 2002, 44 patients (35 females and 9 males with a median age of 62 years) suffering from uncomplicated mild acute biliary pancreatitis were treated in our unit. All patients were electively submitted to surgery after subsidence of the acute symptoms, and for definitive treatment we favored the single-stage laparoscopic management, avoiding preoperative ERCP. All patients underwent laparoscopic cholecystectomy plus fluoroscopic intraoperative cholangiogram (IOC). If filling defect(s) were detected in the IOC, a finding suggestive of concomitant choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) was added in the same sitting. Twenty patients were operated upon within 2 weeks since the attack of the acute symptoms and constitute the early group (n=20), whereas 24 patients underwent an operation later on and constitute the delay group (n=24). We retrospectively compare the safety, effectiveness, and outcome after the single-stage laparoscopic management between the two groups of patients. Laparoscopic cholecystectomy alone constituted the definitive treatment in 38 patients, while an additional LCBDE was performed in the remaining 6 patients (14%), and all operations were achieved laparoscopically. There was no statistically significant difference between the groups in terms of operative time, incidence of concomitant choledocholithiasis, morbidity rate, and postoperative hospital stay. During the follow-up, none of the patients experienced recurrent pancreatitis. In uncomplicated mild acute biliary pancreatitis cases, a single-stage definitive laparoscopic management, avoiding preoperative ERCP, can be safely performed during the same admission, after the improvement of symptoms and local inflammation. Postoperative ERCP should be selectively used in patients in whom the single-stage method failed to resolve the problem.

Influencia del drenaje biliar prequirúrgico en el postoperatorio de la duodenopancreatectomía cefálica

Pancreatoduodenectomy is the only potentially curative treatment for peripapillary tumors. However, postoperative mortality remains as high as 5% and as many as 50% of patients have postoperative morbidity. Preoperative endoscopic retrograde cholangiopancreatography and placement of a biliary drainage stent aim to achieve a precise diagnosis, reduce jaundice and improve the results of surgery for biliary malignancies, but the effectiveness of preoperative biliary drainage in the prevention of postoperative infections is controversial. A retrospective analysis was performed in a series of 58 patients with periampullary tumors who underwent pancreatoduodenectomy and the relationship between preoperative biliary drainage and postoperative complications was examined. Biliary drainage (25.8%) before pancreatoduodenectomy was significantly associated with more frequent biliary and pancreatic anastomotic leakage (60% with drainage versus 20.9% without drainage), higher postoperative morbidity, and greater mean postoperative length of hospital stay (33.3 days with drainage versus 21.6 without drainage). No significant difference was found between the two groups in postoperative mortality at 30 days (13.7%). The effectiveness of biliary drainage before surgery in patients with pancreatic and peripancreatic lesions has not been well established, but we believe that this procedure should be avoided whenever possible in patients with potentially resectable pancreatic and peripancreatic lesions. Prospective randomized studies are required to clarify the indications for preoperative biliary drainage in these patients.

Is There a Role for Routine Preoperative Endoscopic Retrograde Cholangiopancreatography for Suspected Choledocholithiasis in Children?

Endoscopic retrograde cholangiopancreatography (ERCP) is frequently used preoperatively in adult patients with suspected choledocholithiasis. Cholelithiasis occurs much less often in children, and the indications for ERCP are not established. We hypothesized that the natural history of choledocholithiasis in children is spontaneous passage of stones through the papilla and that these children can be managed without routine preoperative ERCP. Retrospective analysis of patients treated over a 10-year period. Tertiary care children's hospital. All patients with cholecystectomy for biliary disease. Cholecystectomy; intraoperative cholangiography for suspected choledocholithiasis: hyperbilirubinemia, gallstone pancreatitis, and ultrasonographic evidence of common bile duct dilation or common bile duct stones; and postoperative ERCP for symptomatic choledocholithiasis: pain and jaundice. Incidence and complications of choledocholithiasis and frequency of ERCP. One hundred patients (63 females) were studied. Indications included acute cholecystitis (10%), chronic cholecystitis (59%), gallstone pancreatitis (26%), and choledocholithiasis (5%). An intraoperative cholangiography was performed in 45 patients, and common bile duct stones were identified in 13. Expectant management of asymptomatic common bile duct stones was associated with sonographic resolution within 1 week. One patient with intraoperative cholangiography-proven choledocholithiasis required ERCP for symptoms 24 hours after operation. One additional patient, who did not undergo intraoperative cholangiography, developed symptomatic choledocholithiasis and required ERCP. There were no choledocholithiasis- or ERCP-related complications. This study suggests that choledocholithiasis occurs frequently in children and that spontaneous passage of common bile duct stones is common. This could explain the relatively high incidence of gallstone pancreatitis. Conservative management of choledocholithiasis is successful in the majority of patients. Routine preoperative or postoperative ERCP is usually not indicated.

The Role of Magnetic Resonance Cholangiography in the Management of Patients With Gallstone Pancreatitis

To examine the utility of magnetic resonance cholangiography (MRC) in the preoperative evaluation of patients with gallstone pancreatitis. Gallstone pancreatitis is often associated with the presence of common bile duct (CBD) stones that may require endoscopic removal prior to planned laparoscopic cholecystectomy. No reliable clinical criteria exist, however, that can accurately predict CBD stones and the need for preoperative endoscopic retrograde cholangiopancreatography (ERCP). Sixty-four patients were identified with gallstone pancreatitis based on clinical presentation and imaging studies over a three-and-a-half-year period. All patients underwent MRC, and the images were evaluated for gallstones, CBD stones, cholecystitis, and pancreatitis Seventeen of the 64 patients (27%) with gallstone pancreatitis were found to have CBD stones confirmed by ERCP. MRC correctly predicted CBD stones in 16 of the 17 patients (sensitivity = 94%). In 1 additional patient, MRC demonstrated CBD stones not seen at ERCP, consistent with probable passage. By comparison, the sensitivities of other criteria for predicting CBD stones were (1) elevated bilirubin >or=2.0 mg/dL = 65%; (2) dilated duct on ultrasound = 55%; and (3) CBD stones on ultrasound = 27%. MRC was able to visualize gallbladder stones in 57 of 62 patients (94%) and correctly predicted acute cholecystitis in 6 of 8 patients. MRC also detected peripancreatic edema and inflammatory changes consistent with acute pancreatitis in 45 of 64 patients (70%). These results demonstrate that MRC can accurately identify CBD stones preoperatively in patients with gallstone pancreatitis and provide valuable information with respect to other biliary pathology, including cholelithiasis, acute cholecystitis, and pancreatitis. MRC is an effective noninvasive screening tool for CBD stones, appropriately selecting candidates for preoperative ERCP and sparing others the need for an endoscopic procedure with its associated complications.

Selection criteria for preoperative endoscopic retrograde cholangiopancreatography before laparoscopic cholecystectomy and endoscopic treatment of bile duct stones: Results of a retrospective, single center study between 1996-2002

The optimal treatment for bile duct stones (in terms of cost, complications and accuracy) is unclear. The aim of our study was to determine the predictive factors for preoperative endoscopic retrograde cholangiopancreatography (ERCP). Patients undergoing preoperative ERCP (< or =90 d before laparoscopic cholecystectomy) were evaluated in this retrospective study from the 1st of January 1996 to the 31st of December 2002. The indications for ERCP were elevated serum bilirubin, elevated liver function tests (LFT), dilated bile duct (> or =8 mm) and/or stone at US examination, coexisting acute pancreatitis and/or acute pancreatitis or jaundice in patient's history. Suspected prognostic factors and the combination of factors were compared to the result of ERCP. Two hundred and six preoperative ERCPs were performed during the observed period. The rate of successful cannulation for ERC was (97.1%). Bile duct stones were detected in 81 patients (39.3%), and successfully removed in 79 (97.5%). The number of prognostic factors correlated with the presence of bile duct stones. The positive predictive value for one prognostic factor was 1.2%, for two 43%, for three 72.5%, for four or more 91.4%. Based on our data preoperative ERCP is highly recommended in patients with three or more positive factors (high risk patients). In contrast, ERCP is not indicated in patients with zero or one factor (low risk patients). Preoperative ERCP should be offered to patients with two positive factors (moderate risk patients), however the practice should also be based on the local conditions (e.g. skill of the endoscopist, other diagnostic tools).

Laparoscopic common bile duct exploration.

Herein I describe my >12-year experience with laparoscopic common bile duct exploration (LCBDE). From 21 September 1989 through 31 December 2001, 3,580 patients presented with symptomatic biliary tract disease. Laparoscopic cholecystecomy (LC) was attempted in 3,544 of them (99.1%) and completed in 3,527 (99.5%). Laparoscopic cholangiograms (IOC) were performed in 3,417 patients (96.4%); in 344 cases (9.7%), the IOC was abnormal. Forty-nine patients (1.4%) underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP), and 33 patients (0.9%) underwent postoperative ERCP. LCBDE was attempted in 326 cases and completed in 321 (98.5%). It was successful in clearing the duct in 317 of the 344 patients with abnormal cholangiograms (92.2%). The mean operating time for all patients undergoing LC with or without cholangiograms or LCBDE or other additional surgery was 56.9 min. Mean length of stay was 22.1 h. The mean operating time for LC only patients ( n = 2530)--that is, those not undergoing LCBDE or any other additional procedure--was 47.6 min; their mean postoperative length of stay was 17.2 h. Ductal exploration was performed via the cystic duct in 269 patients, (82.5%) and through a choledochotomy in 57 patients (17.5%). T-tubes were used in patients in whom there was concern for possible retained debris or stones, distal spasm, pancreatitis, or general poor tissue quality secondary to malnutrition or infection. In cases where choledochotomy was used, a T-tube was placed in 38 patients (67%), and primary closure without a T-tube was done in 19 (33%). There were no complications in the group of patients who underwent choledochotomy and primary ductal closure without T-tube placement or in the group in whom T-tubes were placed. Common bile duct (CBD) stones still occur in 10% of patients. These stones are identified by IOC. IOC can be performed in >96.4% of cases of LC. LCBDE was successful in clearing these stones in 97.2% of patients in whom it was attempted and in 92.2% of all patients with normal IOCs. Most LCBDEs in this series were performed via the cystic duct because of the stone characteristics and ductal anatomy. Selective laparoscopic placement of T-tubes in patients requiring choledochotomy (67%) appears to be a safe and effective alternative to routine T-tube drainage of the ductal system. ERCP, which was required for 5.8% of patients with abnormal cholangiograms, and open CBDE, which was used in 2.0%, still play an important role in the management of common bile duct pathology. The role of ERCP, with or without sphincterotomy, has returned to its status in the prelaparoscopic era. LCBDE may be employed successfully in the vast majority of patients harboring CBD stones.

Current Management of Common Bile Duct Stones in a Teaching Community Hospital

The advent of laparoscopic cholecystectomy (LC) has complicated management of common bile duct (CBD) stones. While LC is routine, laparoscopic CBD exploration (LCBDE) is not, and an algorithm to manage suspected choledocholithiasis has not been uniformly accepted. We evaluated current management of choledocholithiasis. Patients suspected of having CBD stones over a 2-year period were evaluated, and 42 studies in the literature were reviewed. Thirty-two patients were identified. Fourteen patients (44%) had LC with intraoperative cholangiogram (IOC) with no preoperative studies. IOC revealed CBD stones in nine (64%). Seven had CBD exploration (CBDE) at cholecystectomy, and two had postoperative endoscopic retrograde cholangiopancreatography (ERCP). CBDE was successful in five cases, and ERCP was successful in one. Eighteen patients (56%) underwent preoperative ERCP. Five (28%) had no CBD stones. ERCP removed stones in nine patients, and four had open CBDE after failed ERCP. Current literature supports LC with IOC without any preoperative studies. Laparoscopic CBDE is highly successful but depends on surgeon experience. Removing CBD stones with ERCP is also very successful but is associated with increased cost, hospital stay, and complications. We conclude that LC with IOC should be performed without preoperative ERCP when choledocholithiasis is suspected. If found, stones should be removed laparoscopically if possible.

Single-stage definitive laparoscopic management in mild acute biliary pancreatitis.

Population-based studies have shown that nearly one third of patients with acute biliary pancreatitis undergo endoscopic retrograde cholangiopancreatography (ERCP) before undergoing laparoscopic cholecystectomy (LC) (two-stage approach). The present study was designed to evaluate the safety of single-stage laparoscopic management to avoid preoperative ERCP. Between June 1998 and June 2002, 35 female patients and 10 male patients (median age, 59 years) with uncomplicated mild acute biliary pancreatitis were studied prospectively and reviewed retrospectively. LC with fluoroscopic intraoperative cholangiography (IOC) or with fluoroscopic IOC and laparoscopic CBD exploration in cases of concomitant choledocholithiasis was performed as the definitive treatment (single-stage approach). Patients underwent surgery electively when symptoms had subsided and laboratory parameters had improved. LC alone was performed in 39 patients, and an additional laparoscopic CBD exploration was performed in the remaining six. In one patient, IOC yielded a false-positive result. CBD stones were detected in four cases, and debris in the CBD in one case, for an 11% incidence of concomitant choledocholithiasis. The conversion rate was zero, and single-stage laparoscopic treatment was successful in all cases. The overall morbidity rate was 4%. The 30-day postoperative mortality rate was zero. Although preoperative ERCP and sphincterotomy still have a role in complicated cases of mild acute biliary pancreatitis, laparoscopic single-stage definitive treatment is feasible and safe in uncomplicated cases of disease when local experience is available.

Laparoscopic cholecystectomy in octogenarians

This study aimed to assess the outcome of laparoscopic cholecystectomy (LC) in patients 80 years old or older. All consecutive patients 80 years old or older who underwent LC for symptomatic gallstone disease were evaluated. Data analysis included patients' age, gender, indication for surgery, comorbid condition, American Society of Anesthesiology (ASA) score, preoperative endoscopic retrograde cholangio pancreatography (ERCP), intraoperative cholangiogram, operative time, conversion to open surgery, morbidity, mortality, and length of stay. In this study, 67 patients (31 men and 36 women) with a mean age of 84 years (range, 80-90 years) were evaluated. Of these 67 patients, 38 (57%) underwent surgery for complicated diseases including acute cholecystitis in 15 patients (22%), gallstone pancreatitis in 17 patients (25%), cholangitis in 3 patients (4.5%), and obstructive jaundice in 3 patients (4.5%). A total of 38 patients (57%) had a preoperative ASA of 3 or 4; 23 (34%) had a preoperative ERCP; and 6 (9%) had intraoperative cholangiogram. The mean operative time was 94 +/- 20 min. Five patients (7.4%) underwent conversion to open surgery because of unclear anatomy. Complications occurred in 12 patients (18%) including pulmonary edema in 3 patients, myocardial infarction in 1 patient, atelectasis in 2 patients, common bile duct injury in 1 patient, urinary tract infection in 2 patients, wound infection in 2 patients, and intraabdominal infected hematoma in 1 patient. The mean length of stay was 5.3 days. There was no mortality. In octogenarians LC is safe and associated with acceptable morbidity and mortality. Therefore, it should be considered for this age group. The relatively high incidence of complicated gallstone disease in this age group may be decreased if surgery is offered to them at earlier stage of the disease, leading to further decrease in perioperative morbidity.

Magnetic resonance imaging in evaluation of the common bile duct.

The ideal method for evaluation of the common bile duct (CBD) before or during cholecystectomy remains controversial. Magnetic resonance cholangiography (MRC) is a new, promising technique. A prospective evaluation is reported. Sixty-one patients (45 women) were studied by MRC. There were 29 patients with symptomatic gallstone disease and without clinical, biochemical or ultrasonographic evidence of CBD stones (group 1); 28 of them also underwent intraoperative cholangiography (IOC). In addition, there were 21 patients with symptomatic gallstone disease, with mild biochemical and ultrasonographic signs of CBD involvement (group 2), of whom 19 underwent IOC, and 11 patients with symptomatic CBD stones (group 3), nine of whom had preoperative endoscopic retrograde cholangiopancreatography (ERCP) following MRC. MRC showed that no patient in group 1 and three patients in group 2 had CBD stones. Three patients (one in group 1, two in group 2) did not undergo IOC because of technical or clinical problems. In group 3, ERCP confirmed the results of MRC in nine patients. Two patients underwent open surgery because of ultrasonographic, MRC and radiographic signs of pancreatic malignancy. MRC could replace IOC and ERCP for identification of asymptomatic CBD stones. In symptomatic patients MRC combined with other non-invasive imaging techniques can direct the surgeon to appropriate management.

DUPLICATE GALLBLADDER DIAGNOSED WITH ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY AND TREATED WITH LAPAROSCOPIC CHOLECYSTECTOMY

A 44‐year‐old man was admitted to hospital because of sudden severe postprandial right epigastric pain. Abdominal echography showed multiple calculi in the gallbladder and evidence of a probable septum at the neck. Based on the results, tentative diagnoses were made of gallbladder calculosis with associated gallbladder curvature or malformation, and gallbladder adenomyomatosis. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) revealed a duplicate gallbladder consisting of two cystic ducts with two connected gallbladders. Laparoscopic cholecystectomy (Lap‐C) was performed. Inflammation of the Calot's triangle was mild. The two cystic ducts with one common bile duct were identified, and the cystic ducts separated by individual clipping. Duplicate gallbladder, a malformation of the gallbladder, has been reported to occur at an incidence of 0.02%. To date, a total of 60 cases have been reported in Japan, and recent cases have been treated with Lap‐C. In the present case, the surgery could be safely performed because the bifurcation of the cystic ducts could be identified by preoperative ERCP.

Preoperative selective endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy without cholangiography.

The aim of this study was to show that laparoscopic cholecystectomy can be performed safely without routine intraoperative cholangiography. We performed a retrospective analysis of 1750 consecutive patients (1170 females and 580 males with a mean age of 51 years) who underwent laparoscopic cholecystectomy between January 1991 and January 2000. In all, 193 patients (11%) were selected to undergo preoperative endoscopic retrograde cholangiopancreatography (ERCP) on the basis of several criteria for risk of stones. No patients underwent intraoperative cholangiography. ERCP allowed us to make a diagnosis of biliary stones in 62.7% (121 cases). Extraction of the stones was successful in 96% of the cases. In 12% of cases ERCP findings were normal; in the remaining 26.3%, useful diagnostic information was obtained. There were three complications (bleeding and pancreatitis) after endoscopy (complication rate: 1.5%). Laparoscopic cholecystectomy was successful in 92.7% of patients, with a postoperative morbidity rate of 3% (0.5% of major complications). There were no deaths in this series. During a mean follow-up of 60 months (range, 12-120), 7 patients (0.43%) were found to have residual biliary stones (5 had not had preoperative ERCP). The study confirms the hypothesis that laparoscopic cholecystectomy can be safely performed without routine intraoperative cholangiography, with selective use of preoperative ERCP.

The case for laparoscopic common bile duct exploration.

The modern surgeon's approach to choledocholithiasis depends his or her view of cholangiography. During the early 1990 there was a swing away from cholangiography, which had previously been common practice. This was because of perceptions of difficulty with the technique, the time it took, and perhaps an implied increase in costs because of the time factor. There was no evidence on which to base this decision. This led to a marked upswing in the use of endoscopic retrograde cholangiopancreatography (ERCP). There were a large number of ERCPs with normal results performed prior to laparoscopic cholecystectomy. This paper states the case for intraoperative cholangiography and common bile duct clearance at the time of cholecystectomy. It is hoped that this technique will be adopted so patients can undergo a single procedure to remove their gallstones and common bile duct stones if they exist and to decrease the incidence of normal preoperative ERCPs and the need for a second procedure postoperatively to clear stones if they are found.

Current management of common bile duct stones: Is there a role for laparoscopic cholecystectomy and intraoperative endoscopic retrograde cholangiopancreatography as a single-stage procedure?

Background. Although laparoscopic cholecystectomy (LC) and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) have revolutionized the management of secondary common bile duct (CBD) stones, the use of these modalities as a single-stage procedure remains controversial. The aim of this study is to determine whether LC and intraoperative ERCP as a single procedure has any advantages to LC and either preoperative or postoperative therapeutic ERCP performed in 2 stages. Methods. A retrospective 5-year review involved all patients undergoing both LC and ERCP for management of CBD stones from January 1997 to December 2001. Patients were categorized into 3 groups: (1) preoperative ERCP, followed by LC (ERCP then LC); (2) LC, followed by postoperative ERCP (LC then ERCP); and (3) LC with intraoperative ERCP as a single procedure (LC/ERCP). Results. Sixty-seven patients were treated for secondary CBD stones. Forty-three patients underwent ERCP then LC, 10 underwent LC then ERCP, and 14 patients underwent LC/ERCP. There were no differences among the groups in terms of patient demographics or overall complication rates. CBD access and stone clearance was achieved in all 67 (100%) patients, with 1 mild ERCP-related complication in the ERCP-then-LC group. Overall complication rates, hospital length of stay, and total hospital charges were not statistically different among the 3 groups. Conclusion. Single-stage LC/ERCP provides efficacious therapy for CBD stones and may be beneficial in select patients who may not tolerate a second anesthetic procedure. (Surgery 2002;132:729-37.)