Retained CBD Stones Research Articles

Fenestrating vs reconstituting laparoscopic subtotal cholecystectomy: a systematic review and meta-analysis.

Laparoscopic cholecystectomy is one of the most frequently performed procedures by general surgeons. Strategies for minimizing bile duct injuries including use of the critical view of safety method, as outlined by the SAGES Safe Cholecystectomy Program, are not always possible. Subtotal cholecystectomy has emerged as a safe "bail-out" maneuver to avoid iatrogenic bile duct injury in these difficult cases. Strasberg and colleagues defined two main types of subtotal cholecystectomies: reconstituting and fenestrating. As there is a paucity of studies comparing the two subtypes of laparoscopic subtotal cholecystectomy (LSC), we performed a systematic review and meta-analysis comparing the reconstituting and fenestrating techniques for managing the difficult gallbladder. A search of PubMed, Embase, and Cochrane databases was conducted to identify prospective and retrospective studies comparing fenestrating and reconstituting LSC. The outcomes of interest were bile leak, reoperation, readmissions, completion cholecystectomy, postoperative ERCP, and retained CBD stones. We screened 2855 studies and included 13 studies with a total population of 985 patients. Among them, 330 patients (33.5%) underwent reconstituting LSC and 655 patients (55.5%) underwent fenestrating LSC. Twelve studies were retrospective, and one was prospective. Notably, reconstituting STC was associated with decreased incidence of bile leak (OR 0.29; CI 95% 0.16-0.55; p = 0.0002; I2 = 36%). We also noted increased rates of postoperative ERCP with fenestrating STC in sensitivity analysis (OR 0.32; CI 95% 0.16-0.64; p = 0.001; I2 = 31%). In addition, there was no difference between the two techniques regarding the rates of completion of cholecystectomy, reoperation, readmission, and retained CBD stones. Fenestrating LSC leads to a higher incidence of postoperative bile leakage. In addition, our sensitivity analysis revealed that the fenestrating technique is associated with a higher incidence of postoperative ERCP. Further randomized trials and studies with longer-term follow-up are still necessary to better understand these techniques in the difficult gallbladder cases.

ThP6.1 - Revisiting outcomes of laparoscopic cholecystectomy in an elderly population

Abstract Aims Laparoscopic cholecystectomy in the elderly patient is a challenging operation with variable outcomes. We evaluate the outcome of patients who underwent laparoscopic cholecystectomy in a hospital that serves a large ageing population. Methods Retrospective analysis of 53 patients over the age of 70 years who underwent cholecystectomy between January and December 2023. Outcomes were compared between elective vs emergency procedures, indications, age groups (70-74, 75-79, 80-84, 85+) and Charlson comorbidity index (CCI). Results The mean age was 77±4.9 years, and the mean CCI was 4±1. Of 53 procedures performed, 30.2% (n=16) were emergency and 69.8% (n=37) were elective. 6.3% (n=1) was converted to open. 11.3% (n=6) of patients underwent Rendezvous ERCP. Emergency patients had increased length of stay (LOS) (5.1±2.8 vs 1.6±4.1, p=0.04). The indication for surgery was noted to have a significant influence on LOS (p=0.003), however, age groups and CCI did not influence LOS. Non-biliary complications occurred in 13.2% (n=7) of patients. 7.5% (n=4) of patients had readmission within 30 days. 3.75% (n=2) had retained CBD stone and underwent postoperative ERCP. No significant differences between age groups in relation to complications were identified. Conclusions Emergency cholecystectomy in patients over the age of 70 is associated with a longer LOS. Rates of complications are not influenced by age or CCI. Laparoscopic Cholecystectomy can be safely offered to a diverse elderly population.

Various Surgical Management of Post-ERCP Retained CBD Stones

Various Surgical Management of Post-ERCP Retained CBD Stones

Ligature Technique: A Safe Outcome in Laparoscopic Cholecystectomy

Objective: To compare Extracorporeal Sliding knot (ECK) and clip ligation to ligation of the cystic duct in laparoscopic cholecystectomy. Patients and Methods: This study was conducted as prospective randomized study in Jeddah National Hospital in Jeddah Saudi Arabia, in surgical department carried out from June 2018 to June 2019. In the study 100 patients were selected and divided into two groups, in which we compared outcomes of patients in whom Cystic Duct Occlusion was done by clips (Group I n=60) and other group Ligatures endoloop knotting (Group II n=40). During laparoscopic cholecystectomy (LC), cystic duct occlusion can be done with titanium clips or ligature permanently in order to prevent leakage of bile into the peritoneal cavity. Results: Average age of the patients of clipping group was 43.68 years and the average age of the patients of knot group was 42.64 years, with male to female ration as 1:4.5. 1:2.3 of clipping and knot group respectively. Regarding operating time from initial incision to closure of wound is 61 to 65 minutes in clip group and 69 to 70 minutes in knot group. Longer operating times in knot group is due to learning curve effect for most surgeons as is evident from the fact that first twenty surgeries took longer time as compared to subsequent surgeries. The port site infection was in 03 cases of the clip group 01 in the knot group, drain was kept in 12 cases in knot group and 06 in clip group, bile leak requiring ERCP 02 cases in clip group and 01 in knot group, retained CBD Stones 01 was in clip group, obstructive Jaundice was seen in one cases of clip group, while no mortality was seen in both groups. Although the hospital stay after surgery in clip group was 1-2 days and in knot group also 1-2 days and in ERCP patients’ Hospital stay was 2 to 3 days. Conclusion: Cystic duct occlusion with knots/ligatures is a safe, cost effective, less post operative pain alternative to clips as various studies showed clips complications. It also showed less post-operative pain, less bile leak and port site wound infection. Safety of using knots/ligatures is even better than clips as is evident from this study comparing these two methods of cystic duct occlusion. Key words: cholecystectomy, surgical clips, surgical knots, surgical ligature, cystic duct occlusion, bile leakage

Efficacy and safety of laparoscopic common bile duct exploration via choledochotomy with primary closure for the management of acute cholangitis caused by common bile duct stones

BackgroundT-tube drainage after laparoscopic common bile duct exploration (LCBDE) has been demonstrated to be safe and effective for patients with acute cholangitis caused by common bile duct stones (CBDSs). The outcomes after LCBDE with primary closure in patients with CBDS-related acute cholangitis are unknown. The present study aimed to evaluate the efficacy and safety of LCBDE with primary closure for the management of acute cholangitis caused by CBDSs.MethodsBetween June 2015 and June 2020, 368 consecutive patients with choledocholithiasis combined with cholecystolithiasis, who underwent laparoscopic cholecystectomy (LC) + LCBDE in our department, were retrospectively reviewed. A total of 193 patients with CBDS-related acute cholangitis underwent LC + LCBDE with primary closure of the CBD (PC group) and 62 patients underwent LC + LCBDE followed by T-tube placement (T-tube group). A total of 113 patients who did not have cholangitis were excluded. The clinical data were compared and analyzed.ResultsThere was no mortality in either group. No significant differences were noted in morbidity, bile leakage rate, retained CBD stones, or readmission rate within 30 days between the two groups. Compared with the T-tube group, the PC group avoided T-tube-related complications and had a shorter operative time (121.12 min vs. 143.37 min) and length of postoperative hospital stay (6.59 days vs. 8.81 days). Moreover, the hospital expenses in the PC group were significantly lower than those in the T-tube group ($4844.47 vs. $5717.22). No biliary stricture occurred during a median follow-up of 18 months in any patient. No significant difference between the two groups was observed in the rate of stone recurrence.ConclusionsLCBDE with primary closure is a safe and effective treatment for cholangitis caused by CBDSs. LCBDE with primary closure is not inferior to T-tube drainage for the management of CBDS-related acute cholangitis in suitable patients.

Reinterventions following laparoscopic cholecystectomy and bile duct exploration. A review of prospective data from 5740 patients

BackgroundComplications following laparoscopic cholecystectomy (LC) and common bile duct exploration (CBDE) for the management of gallstones or choledocholithiasis impact negatively on patients’ quality of life and may lead to reinterventions. This study aims to evaluate the causes and types of reintervention following index admission LC with or without CBDE.MethodsA prospectively maintained database of LC and CBDE performed by a single surgeon was analysed. Preoperative factors, difficulty grading and perioperative complications requiring reintervention and readmissions were examined.ResultsReinterventions were required in 112 of 5740 patients (2.0%), 89 (1.6%) being subsequent to complications. The reintervention cohort had a median age of 64 years, were more likely to be females (p < 0.0023) and to be emergency admissions (67.9%, p < 0.00001) with obstructive jaundice (35.7%, p < 0.00001). 46.4% of the reintervention cohort had a LC operative difficulty grade IV or V and 65.2% underwent a CBDE. Open conversion was predictive of the potential for reintervention (p < 0.00001). The most common single cause of reintervention was retained stones (0.5%) requiring ERCP followed by bile leakage (0.3%) requiring percutaneous drainage, ERCP and relaparoscopy. Relaparoscopy was necessary in 17 patients and open surgery in 13, 6 of whom not resulting from complications. There were 5 deaths.ConclusionThis large series had a low incidence of reinterventions resulting from complications in spite of a high workload of index admission surgery for biliary emergencies and bile duct stones. Surgical or endoscopic reinterventions following LC alone occurred in only 0.8%. The most common form of reintervention was ERCP for retained CBD stones. This important outcome parameter of laparoscopic biliary surgery can be optimised through early diagnosis and timely reintervention for complications.

ASSESSMENT OF RISK FACTORS AND COMPLICATIONS OF LAPAROSCOPIC CHOLECYSTECTOMY

Cholecystectomy is one of the most common abdominal surgical procedures in developed countries. 74 patients of cholecystectomy of both genders were enrolled. was recorded. A thorough clinical examination was done. Lipid profile, Etiology and complications were recorded. Common etiology found to be cholestasis in 38, hyperlipidemia in 24, hereditary spherocystosis and idiopathic cases. The difference was significant (P&lt; 0.05). Complications were intraoperative bleeding, biliary peritonitis, intra-abdominal collections bile duct injury, ligation of CBD, bile leakage, SSI, and retained CBD stones cases. The difference was significant (P&lt; 0.05). Authors found that common etiology found to be cholestasis, hyperlipidemia, hereditary spherocystosis and idiopathic.

PWE-083 Deranged liver function tests are more indicative of choledocholithiasis in cholecystitis than in patients with gall stone pancreatitis

Introduction On table cholangiogram (OTC) is routinely done in patients with deranged liver function tests at the time of laparoscopic cholecystectomy in the setting of acute cholecystitis to rule out choledocholithiasis. However, its role in patients presenting with gall stone pancreatitis is uncertain. Method A prospective longitudinal cohort study including all consecutive patients who underwent emergency cholecystectomy over a six month period in a busy tertiary centre was undertaken. Demographic data, liver function tests (LFT) and OTC findings of patients who presented with cholecystitis and gall stone pancreatitis were analysed. Differences in levels of bilirubin, alkaline phosphatase and alanine aminotransferase in two subgroups of patients: cholecystitis and gall stone pancreatitis and their relation to presence or absence of choledocholithiasis on OTC was analysed. Statistical analysis was done using Mann-Whitney test. Results 145 patients (Age: 50; range:16–85, M:F = 44:101) were admitted on an emergency basis over a six month period. 116 patients presented with cholecystitis and 29 patients (20%) had gall stone pancreatitis. Of these 29 patients, 24 (82.8%) had OTC at the time of cholecystectomy. At OTC, 13 (54%) had no stones, while 11 (46%) did have stones. There was no significant difference in levels of bilirubin, alkaline phosphatase and alanine aminotransferase between CBD stone positive and stone negative patients (Bilirubin: 28 v 22; U(df)=59.00, p = 0.49, Alkaline phosphatase: 211 v 145; U(df)=55.00, p = 0.35, Alanine aminotransferase: 273 v 240; U(df)=63.00, p = 0.64; Mann-Whitney test). Of the 116 patients with cholecystitis, 38 (32.8%) had OTC at the time of cholecystectomy. At OTC, 21 (55.3%) had no stones, while 17 (44.7%) did have stones. There was significant difference in levels of bilirubin, alkaline phosphatase and alanine aminotransferase between CBD stone positive and stone negative patients (Bilirubin: 42 v 14; U(df)=34.50, p= Conclusion Deranged LFT in a setting of cholecystitis is more predictive of choledocholithiasis as opposed to gall stone pancreatitis. The passage of stone via CBD triggering gall stone pancreatitis may be responsible for deranged LFT rather than retained CBD stones. Hence it is more important to do OTC in patients with cholecystitis and deranged LFT than in patients with gall stone pancreatitis. Disclosure of interest None Declared.

Management of Obstractive Jaundice Due to Common Bile Duct Stone in Baghdad Teaching Hospital.

Background: the most common cause of obstructive jaundice is CBD stones, and these can produce significant morbidity and mortality. The management of the obstructive jaundice due to CBD stones is in evolution; several methods of investigations and treatment have been introduced, and each one has its own advantages and disadvantages.&#x0D; Objective: to study and evaluate the management of obstructive jaundice due to CBD stones in Baghdad teaching hospital.&#x0D; Results: from the 125 patients presented with obstructive jaundice included in this study 14 patients were found to have a periampullary lesions, and they were excluded from the study, so the total number of the patients was 111; 46 males and 65 females Endoscopic management was done for 108 patients with success rate of 90%. Surgical treatment was required in 13 patients, 10 of them following failure of ERCP and the other 3 patients were those with Mirizzi syndrome. The most common complication of ERCP was acute pancreatitis and the most common cause of failure to extract the stones was the size of stone (more than 15mm)Patients and methods: a prospective study of 111 patients with clinical, laboratory, and imaging features suggestive of obstructive jaundice due to CBD stones who were managed in Baghdad teaching hospital over the period from January 2011 to November 2011; other 14 patients with obstructive jaundice due to other causes were excluded. . All patients were symptomatic and had abnormal liver function tests. Transabdominal US was done for all of them, MRCP for 26 patients, and EUS for 9 patients. Four patients had primary stones, 95 patients had secondary stones, 9 patients had retained stones and 3 patients had Mirizzi syndrome.Those patients were subjected to ERCP both to prove the diagnosis and extract the CBD stones. Only three patients sent directly for surgical treatment because they were diagnosed as Mirizzi syndrome. Surgical treatment also was offered for those patients in whom endoscopic management failed. &#x0D; Conclusions: Endoscopic sphincterotomy and stone extraction followed by laparoscopic&#x0D; cholecystectomy is still considered the orthodox treatment of CBD stones. Large and multiple CBD stones are the most common causes of failure of endoscopic extraction and indication for surgical treatment. There was higher incidence of retained CBD stones in our study than what was reported in western countries, because there is no intraoperative screening to avoid missing CBD stones in our hospital.&#x0D;

Double Pigtail Stent as Alternative to Commonbile Duct Exploration as Chronic Treatment for Retained CBD Stone

Double Pigtail Stent as Alternative to Commonbile Duct Exploration as Chronic Treatment for Retained CBD Stone

Laparoscopic Common Bile Duct Exploration: Our First 50 Cases

Laparoscopic common bile duct exploration (CBDE) is becoming more popular in the management of choledocholithiasis due to improved laparoscopic expertise and advancement in endoscopic technology and equipment. This study aimed to evaluate the safety and short-term outcome of laparoscopic CBDE in a single institution over a 3-year period. A retrospective review of the records of all patients who underwent laparoscopic CBDE in Tan Tock Seng Hospital between January 2006 and September 2008 was conducted. Fifty consecutive patients, with a median age of 60 years (range, 27 to 85) underwent laparoscopic CBDE for choledocholithiasis during the study period. About half of our patients presented as an emergency with acute cholangitis (32.0%) accounting for the majority. A total of 22 (44.0%) patients underwent laparoscopic CBDE as their primary procedure while the remaining 28 (56.0%) were subjected to preoperative ERCP initially. Of the latter group, documented stone clearance was only documented in 5 (17.9%) patients. Laparoscopic CBDE via the transcystic route was performed in 27 (54.0%) patients while another 18 patients (36.0%) had laparoscopic choledochotomy and 1 patient (2.0%) had laparoscopic choledocho-duodenostomy. There were 4 (8.0%) conversions in our series. The median operative time for laparoscopic CBDE via the transcystic route and the laparoscopic choledochotomy were 170 (75-465) and 250 (160-415) minutes, respectively. For the 18 patients who underwent a laparoscopic choledochotomy, T-tube was inserted in 8 (44.4%) patients while an internal biliary stent was placed in 4 (22.2%) with the remaining 6 patients (33.3%) undergoing primary closure of the choledochotomy. The median length of hospital stay was 2 days (range, 1 to 15) with no associated mortality. The main complications (n = 4, 8.0%) included retained CBD stones and biliary leakage. These were treated successfully with postoperative endoscopic retrograde cholangiopancreatography (ERCP) with/without percutaneous drainage with no further surgery required. Laparoscopic CBDE is a safe operation with good outcome in managing choledocholithasis. Its dividends include the numerous benefits of minimally invasive surgery. If possible, transcystic extraction is preferred to choledochotomy, as this obviates the need for biliary diversion. ERCP will still hold an important role in certain instances in the management of choledocholithiasis.

The Effect of Biliary Stenting with Combined UDCA and Rowachol Administration On Retained CBD Stones -Multicenter Study-

Background & Aim: Endoscopic sphincterotomy and stone extraction is effective treatment of choice for patients with CBD stones. Endoscopic biliary stenting is one of the palliative treatment for the patients with impacted large CBD stones. Long-term treatment with biliary stenting can decrease the size of stone. Choleretic agents, UDCA and Rowachol, may enhance the dissolution of gallstones. We studied the effectiveness of a period of biliary stenting combined with UDCA and Rowachol administration as a medical treatment for difficult CBD stones. Patients & method: Between October 2005 and September 2007, a total of 21 patients (7 men; mean age; 71.5 years) with CBD stones failed on endoscopic removal including mechanical lithotripsy were enrolled. After trying endoscopic stone removal, we had placed 10F plastic stent above the top of stone, and medicated UDCA (600 mg) and Rowachol (300 mg) a day for 6 months (range: 3∼13). At 6 months of medication after initial ERCP or when stent was invisible during follow up, second ERCP was performed. The stone size and CBD diameter before and after stent insertion was compared and endoscopic stone removal was re-tried. Statistical analysis was done by Wilcoxon signed rank test. Result: Initial mean diameters (transverse × longitudinal) of CBD stones were 19.4 × 28.6 mm and decreased to 12.2 × 20.9 mm at 2nd ERCP after biliary stenting with medication (p < 0.05). Mean diameter of CBD measured at cystic duct insertion level was 22.6 mm and also decreased to 19.9 mm after biliary stenting with medication. Endoscopic stone removal was successful in 19 of 21 patients (90.4%) with mean 1.5 sessions of ERCP. Conclusion: The endoscopic biliary stenting with a period of combined UDCA and Rowachol administration for difficult CBD stones seems to be an effective and safe method as a medical treatment. For more significant results, a randomized, prospective study will be required.

Endoscopic Treatment of Retained CBD Stones By Using a Double-Lumen Basket for FREDDY Laser Lithotripsy

Background/Aim: Mechanical lithotripsy is the first choice for difficult stone resistant to conventional endoscopic treatment procedure. Although high success rate, mechanical lithotripsy can be failed or result in complications, especially in patients with large and hard stones. Laser lithotripsy (LL) with FREDDY is very effective and safe for stone fragmentation. Newly developed double-lumen basket for LL allows laser lithotripsy after capturing of stone by basket. The aim of this study was to evaluate the feasibility and efficacy of laser lithotripsy using double-lumen basket in patients with difficult bile duct stones. Methods: A total of twelve patients with CBD stones in whom conventional endoscopic treatment including mechanical lithotripsy had failed were selected and underwent FREDDY LL using a double-lumen basket. A laser fiber was inserted through the lumen of basket onto the stone surface after capturing of a stone by basket. LL was performed under fluoroscopy until possible to capture of fragmented stone into the basket. Endoscopic removal of fragments was attempted within the same session. Failure was defined as failure to remove all ductal stones/fragments within two lithotripsy sessions. Results: Stones were successfully fragmented in 11 of 12 patients; 11 patients (91.7%) eventually became stone free. Two of 11 patients (16.7%) required more than one session for LL. The mean number of endoscopic treatment sessions was 1.4 for complete stone removal. The fragments were extracted endoscopically after LL in all patients; mechanical lithotripsy was applied in 2/11 (16.7%) patients. Minor complications were noted in four patients (hemobilia in two patients, abdominal pain in two patients). Conclusion: For a selected group of patients with difficult CBD stones, FREDDY laser lithotripsy using double-lumen basket seems to be a safe and effective method. However, continuous development of basket for the better lithotripsy is needed.

Imaging findings of biliary and nonbiliary complications following laparoscopic surgery

Laparoscopic techniques are evolving for a wide range of surgical procedures although they were initially confined to cholecystectomy and exploratory laparoscopy. Recently, surgical procedures performed with a laparoscope include splenectomy, adrenalectomy, gastrectomy, and myomectomy. In this article, we review the spectrum of complications and illustrate imaging features of biliary and nonbiliary complications after various laparoscopic surgeries. Biliary complications following laparoscopic cholecystectomy include bile ductal obstruction, bile leak with bile duct injury, dropped stones in the peritoneal cavity, retained CBD stone, and port-site metastasis. Nonbiliary complications are anastomotic leakage after partial gastrectomy, gangrenous cholecystitis after gastrectomy, hematoma at the anastomotic site following gastrectomy, gastric infarction after gastrectomy, port-site metastasis after gastrectomy, hematoma after splenectomy, renal infarction after adrenalectomy, and active bleeding after myomectomy of the uterus.

7252 The association of biliary leaks with choledocholithiasis following laparoscopic cholecystectomy.

Complications of laparoscopic cholecystectomy has been well described. This list includes bile duct leak, retained stones, and partial or complete biliary transection. Several investigators have documented the efficacy of endoscopic treatment of individual complications. Rare reports have discussed the presence of choledocholithiasis coexisting with bile duct leaks following laparoscopic cholecystectomy. AIM: To determine the success of endoscopic therapy in patients presenting with choledocholithiasis and bile duct leaks following laparoscopic cholecystectomy. METHODS: Sixtythree patients presented over a ten year period with bile duct leaks following laparoscopic cholecystectomy. Of these, 9 patients were found to have concomitant retained bile duct stones. This included 7 woman, 2 men, age range 33-72 (mean 51 years). Cholangiogram demonstrated 7 patients with single stones (5 mm-15 mm, and 2 patients with multiple stones (6 mm-20 mm). Coexisting biliary leaks were noted at the cystic duct stump=8 and accessory duct of Lutscha=1. Patients presented 36 hours-5 days following laparoscopic cholecystectomy. All patients had abdominal pain and abnormal LFTs, 3 patients with N/V, 2 patients with fever, 5 patients with abdominal distension. RESULTS: All patients underwent successful cannulation and opacification of the bile duct. Endoscopic sphincterotomy was performed in all patients prior to stone extraction. Eight of 9 patients had stone extraction accomplished at initial ERCP while 1 of 9 patients required 2 ERCP sessions for complete stone extraction. Biliary stents were placed in all patients (10 Fr=6 patients, 7 Fr=3 patients)over a 4-9 week period (mean 5.5 weeks). Follow-up was available in all patients (range 8 months - 8 years). Resolution of leaks and stone clearance was demonstrated in all patients. No complications were observed in this study. CONCLUSION: Biliary leaks following laparoscopic cholecystectomy are associated with retained CBD stones in nearly 15% of patients. Resolution of bile leaks can be expected following extraction, ES, and stent placement within 4-9 weeks of therapy.

3375 Where do eus and mrcp fit in the management of the patient with acute biliary pancreatitis: a decision analytic model.

Background: In the absence of biliary sepsis, the role of endoscopic retrograde cholangiopancreatography (ERCP)in acute biliary pancreatitis (ABP) is controversial. ERCP has not reliably decreased morbidity or mortality, and procedure-related complications may occur. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography (EUS) are new modalities for CBD visualization that could lower costs and complications related to ERCP.We performed cost-effectiveness and Bayesian analyses of these modalities to define their potential role in ABP. Methods: A decision analytic model of the natural history of ABP was constructed (DATA 3.5, TreeAge Inc., Williamstown, MA). The transition probabilities between health states and test performance characteristics (sensitivity and specificity)were derived from the medical literature using Medline™. All costs(including the diagnostic procedures evaluated) were obtained from Medicare reimbursement rates and supplemented by the medical literature. The strategies evaluated were: 1)ERCP at 48 hours, 2)MRCP at 48 hours followed by ERCP if positive for CBD stone, 3)EUS at 48 hours followed by ERCP if positive for CBD stone and 4) Observation and endoscopic intervention only if biliary sepsis ensued. We compared costs and performed cost-effectiveness analysis between strategies. The outcome measures utilized were total costs, costs per ABP death prevented, costs per ERCP death prevented and costs per stone detected. Results: The total costs per patient with ABP were: Observation $8,821; EUS $9,828; ERCP $9,970; MRCP $10,253. The incremental cost-effectiveness ratio (ICER) per ABP death prevented was equal for ERCP, EUS and MRCP ($900K). The ICER per ERCP-related death prevented was $70K for Observation, $92K for EUS and $95K for MRCP. At a pre-test probability of CBD stones between 0-40%, EUS was the most cost-effective strategy in terms of dollars per stone detected, whereas ERCP was preferable at probabilities >40%. Conclusions: In terms of preventing deaths due to ABP and ERCP, observation is the most cost-effective strategy. From a practical standpoint, if concern exists about retained stones, EUS is most cost-effective, at a pretest probability of stones between 0-40%. If the probability of retained CBD stones is greater than 40%, ERCP is the dominant strategy. Development and validation of clinical predictors of retained CBD stones will facilate cost-effective care in these patients.

Complications of laparoscopic cholecystectomy: the experience of a university-affiliated teaching hospital.

In most published reports on laparoscopic cholecystectomy, the cases have been accrued from small community hospitals in a multicenter fashion. The purpose of this study was to compare the rate of complication following laparoscopic cholecystectomy performed at a single university-affiliated teaching hospital to those quoted in the literature. A retrospective review of the first 1300 laparoscopic cholecystectomies performed at the Videoscopic Surgery Center at Pennsylvania Hospital from May 1990 through January 1994 was undertaken. Complications were classified as those related to creation of the initial pneumoperitoneum and those related to cholecystectomy. A 3% conversion rate to open cholecystectomy (n = 40) was noted due to the presence of dense adhesions, gangrenous cholecystitis, or difficult anatomic relationships. There were 18 complications (1.4%) related to creation of the initial pneumoperitoneum and 14 complications (1.1%) related to cholecystectomy. Complications related to laparoscopy included bleeding from the abdominal wall (n = 2), trocar site hernia (n = 11), hollow viscus injury (n = 1), and wound infection (n = 4). Complications related to cholecystectomy included unanticipated retained CBD stone (n = 5), symptomatic bile leak (n = 6), hollow viscus injury (n = 1), intraabdominal abscess (n = 1), and a retained portion of gallbladder (n = 1). There were no perioperative deaths related to laparoscopic cholecystectomy, and the overall morbidity was 2.4%. Long-term follow-up revealed no cases of benign biliary strictures. With attention to anatomy, technique, and meticulous dissection, laparoscopic cholecystectomy can be safely performed in a university-affiliated teaching hospital setting.

Copper vapor laser fragmentation of gallstones: In vitro measurements of wall heat transmission

Laser fragmentation is a promising new modality in management of retained CBD stones. Recent reports demonstrate the feasibility of lasers for this, but few studies have evaluated their safety (e.g., thermal injury may occur at 43°C). This study was conducted to measure heat transmission from lased bilirubinate and mixed stones to a simulated CBD wall. Four welded thermocouples were passed to the inside wall of 6-mm polyvinyl tubing 90° apart to surround the lumen stone. The thermocouples were interfaced to a computer and temperatures were recorded every 270 msec. The tubing was submerged in a 37°C water bath for all lasing work. A copper vapor laser (wavelength, 510 nm; 5.6 W; 5 kHz; pulse length, 30 ns) was attached to a 650-μm quartz fiber. A stone was “impacted” in the tubing and the laser fiber was pushed against the stone while making multiple passes to fragment it. Thirty mixed gallstones (mean size, 6.9 × 5.1 mm) and 20 bilirubinate gallstones (mean size, 7.1 × 5.2 mm) were fragmented during the study. Maximum temperature ( T max), duration of T max ( T max D ), interval to stone piercing ( T ip), and interval to fragmentation ( T iF) were measured and comparisons were carried out with the SPSS statistical package using the t test procedure. The T max generated during fragmentation of bilirubinate stones (43.4 ± 1.7°C) was significantly less ( P < 0.002) than the T max for mixed stones (54.0 ± 2.7°C) but both T max values represented potentially injurious temperature levels. While less heat was generated during bilirubinate stone fragmentation, T iP and T iF were significantly longer ( P < 0.05) for the bilirubinate stones (14.2 ± 2.2 and 21.3 ± 2.4 sec, respectively) than for the mixed stones (4.6 ± 1.0 and 15.9 ± 1.0 sec, respectively). The mean recorded T max during fragmentation of the two types of gallstones in this study suggests the possibility of CBD thermal injury. The relative greater “hardness” of the bilirubinate stones probably accounted for the longer T iP and T iF when compared to mixed stones. Careful in vivo and clinical studies need to be done to establish the safety of this modality for surgeons.