Suspected Bile Duct Stones Research Articles

Selective cannulation of the common bile duct: a prospective randomized trial comparing standard catheters with sphincterotomes

Background: Current recommendations for the use of standard catheters or sphincterotomes for the initial attempt at selective common bile duct cannulation have been made in the absence of prospective comparative data. Methods: A prospective study was carried out in which patients were randomized to undergo cannulation with a standard catheter or a sphincterotome (standard or wire-guided). Multivariate models were constructed to determine significant independent predictors of the success rates of initial and selective cannulation and the number of attempts and time needed to achieve selective cannulation. Results: Eighty-three successive patients were evaluated; 36 were excluded because they had undergone previous therapeutic endoscopic retrograde cholangiopancreatography (ERCP) or a Billroth II operation. Of the 47 patients (28 women, mean age 60.6 ± 14.5 years), indications for ERCP included suspected bile duct stones in 41 patients, pancreatico-biliary malignancies in 4, and biliary leaks in 2. Eighteen patients were randomized to undergo selective common bile duct cannulation with standard catheter and 29 to standard/wire-guided sphincterotome. Initial common bile duct cannulation for the standard catheter and standard/wire-guided sphincterotome groups was successful in 12 (67% [95% CI: 41%, 87%]) and 28 (97% [95% CI: 82%, 100%]) patients, respectively (95% CI for the difference: –0.57 to –0.03, p = 0.009). Using intention to treat analysis, selective common bile duct cannulation was successful for standard catheter and standard/wire-guided sphincterotome patients in 17 (94% [95% CI: 73%, 99%]) and 28 (97% [95% CI: 82%, 100%]) cases, respectively (95% CI for the difference: –0.15 to +0.10, p > 0.05). The mean number of attempts required to achieve selective common bile duct cannulation were 12.4 ± 6.0 and 2.8 ± 3.1 ( p = 0.0001). The mean time taken to achieve selective common bile duct cannulation was 13.5 ± 6.14 and 3.1 ± 5.1 minutes ( p = 0.0001). Multivariate modeling revealed that the initial choice of catheter was the only significant independent predictor of the time taken and the number of attempts performed to achieve selective common bile duct cannulation ( p = 0.0001 for each model). Conclusion: The use of standard/wire-guided sphincterotome was superior to that of standard catheter for the initial attempt at cannulation of the common bile duct. The number of attempts required may bear clinical significance with regard to the development of post-ERCP pancreatitis and warrants further study. (Gastrointest Endosc 1999;50:775-9.)

Helical computed tomographic cholangiography versus endosonography for suspected bile duct stones: a prospective blinded study in non-jaundiced patients

BACKGROUNDHelical computed tomography performed after intravenous administration of a cholangiographic contrast material (HCT-cholangiography) may be useful for detecting bile duct stones in non-jaundiced patients. However, this method has never been...

Disease-Specific Outcomes Assessment for Common Bile Duct Stones

Clinicians often manage patients with suspected bile duct stones. Research has focused on assessing the accuracy of diagnostic alternatives to endoscopic retrograde cholangiography or on establishing predictors for stones. Studies using costs and quality of life as primary outcomes are rare. This may be caused in part by specific challenges inherent to outcomes research in the field of gastrointestinal endoscopy. It is unlikely that one strategy will be suitable for all; however, once a primary outcome is chosen, knowing what variables most affect this outcome should help clinicians objectively tailor the optimal strategy for their needs. The most important variable may be the risk of symptoms caused by untreated stones. There may be a substantial group of patients who are best managed expectantly (with no bile duct imaging). It may therefore, be useful to obtain better prospective data on the natural history of choledocholithiasis.

Use of magnetic resonance cholangiography in the diagnosis of choledocholithiasis: prospective comparison with a reference imaging method

BackgroundMagnetic resonance cholangiography (MRC) is a new technique for non-invasive imaging of the biliary tract.AimTo assess the results of MRC in patients with suspected bile duct stones as compared with...

Assessment of Indicators for Predicting Choledocholithiasis Before Laparoscopic Cholecystectomy

The objective of this report was to study the sensitivity of indicators used for predicting bile duct stones and their endoscopic removal before laparoscopic cholecystectomy. A retrospective study was conducted on 104 patients who successfully underwent endoscopic retrograde cholangiopancreatogram (ERCP) before laparoscopic cholecystectomy at Riyadh Medical Complex between 1992 and 1994 (1412H-1414H). Six indicatorsâjaundice, biliary pancreatitis, stones in bile duct on sonography, dilated bile duct (>7 mm) on ultrasonography, dilated bile duct with deranged liver function test, and deranged liver function test without jaundiceâwere used for suspecting choledocholithiasis and endoscopic removal before laparoscopic cholecystectomy. Ultrasound correctly predicted bile duct stone in 75%, followed by dilated bile duct with deranged liver function test (46%). Clinical jaundice and biliary pancreatitis were equally sensitive indicators (42% each). Sensitivity of only dilated bile duct on ultrasonography in predicting duct stone was 36%. Deranged liver function without jaundice was the least sensitive (22%) of the predictors. Overall, these indicators correctly diagnosed bile duct stones in 34% of patients. Until laparoscopic exploration of bile duct or a noninvasive technique, such as magnetic resonance cholangiopancreatogram (MRCP), is widely available, these predictors will help in selecting patients with bile duct stones for preoperative removal. Other workers have suggested combining these indicators to improve the predictive value.

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 accuracy of the pre-ERCP diagnosis in patients with suspected bile duct stones or distal bile duct stricture

The accuracy of the pre-ERCP diagnosis in patients with suspected bile duct stones or distal bile duct stricture

Selective preoperative endoscopic retrograde cholangiography with sphincterotomy avoids bile duct exploration during laparoscopic cholecystectomy.

A policy of preoperative endoscopic retrograde cholangiography (ERC) for suspected bile duct stones was used in 1507 patients considered for laparoscopic cholecystectomy in three district general hospitals. Altogether 306 patients underwent ERC, and bile duct cannulation was achieved in 276 (90%). Bile ducts were cleared by endoscopic sphincterotomy in 128 of 161 patients (79%) with proven duct stones. Laparoscopic cholecystectomy was completed in 1396 patients. Ten laparotomies were necessary for complications of laparoscopic cholecystectomy. The complication rate for endoscopic sphincterotomy/laparoscopic cholecystectomy was 2.7%, with no mortality. Overall, a combined endoscopic/laparoscopic approach succeeded in 1386 patients (92%). Fourteen patients (1%) had retained stones during a median of 14 months (range 1-42) follow up, all of which were removed by ERC/endoscopic sphincterotomy. If a policy of selective ERC before laparoscopic cholecystectomy is used for all patients with symptomatic gall stones, most will avoid an open operation and laparoscopic exploration of the bile duct is not necessary.

Laparoscopic Cholecystectomy: The First Year Experience

A total of 307 consecutive patients with symptomatic gallstones were admitted for cholecystectomy. Two hundred seventy patients (88%) were considered suitable for laparoscopic cholecystectomy. Forty-two of these (17%) were admitted on an emergency basis. The procedure was accomplished successfully in 246 patients (91%), while in the remaining 24 patients (9%), the attempt had to be abandoned and converted to open cholecystectomy. Postoperative complications, mostly minor, occurred in 22 patients (9%). Suspected common bile duct stones were treated with endoscopic retrograde cholangiopancreatography (ERCP) prior to surgery. The mean operative time was 82 minutes and 70% of the patients were discharged home within 489 hours after surgery and more than 90% were sent home by the third postoperative day. The results suggest that laparoscopic cholecystectomy is feasible for the majority of patients with symptomatic gallstones.

Prospective evaluation of the use of endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy.

Preoperative cholangiography and subsequent removal of bile duct stones may increase the efficacy of laparoscopic cholecystectomy and reduce the rate of conversion to open cholecystectomy. Since there is little data on the incidence of choledocholithiasis in this group of patients, we undertook a prospective study on the routine performance of ERC in 288 patients selected for laparoscopic cholecystectomy. ERC succeeded in 264 of the 288 patients (91.7%) and showed a normal bile duct system in 227 (86.0%). Atypical bile duct anatomy was seen in eight patients. Open cholecystectomy was performed in seven of them but was judged to be absolutely necessary in only two cases (one patient each with Caroli syndrome and Mirizzi syndrome). ERC also revealed bile duct stones in 29 of 264 patients (11.0%) which had not been suspected on the basis of clinical, laboratory and ultrasonographic findings in nine cases (3.4%). EPT succeeded in all of the 29 patients with choledocholithiasis but open cholecystectomy was subsequently performed in four patients due to incomplete bile duct clearance (n = 3) or temporary bleeding after EPT (n = 1). The rate of ERC/EPT-related morbidity was 2.8%. It is concluded from a risk-benefit analysis in these patients that ERC should be restricted to patients with suspected bile duct stones. Following this strategy, small ductal concrements and bile duct abnormalities will be missed in 6.4% of cases but the clinical relevance of these findings is still unclear. In patients with combined gallbladder and common bile duct stones, preoperative EPT plus subsequent laparoscopic cholecystectomy appears to be an effective and time-saving therapeutic regimen which should be compared with open cholecystectomy plus common bile duct exploration in future studies.