Treatment Of Common Bile Duct Stones Research Articles

Cost-analysis and effectiveness of one-stage laparoscopic versus two-stage endolaparoscopic management of cholecystocholedocholithiasis: a retrospective cohort study

BackgroundOne–stage laparoscopic common bile duct (CBD) stone clearance and laparoscopic cholecystectomy (LCBDE+LC) for cholecystocholedocholithiasis ( CCL) can be performed with similar short and long-term outcomes than two-stage endoscopic retrograde cholangiography followed by subsequent LC (ERCP+LC). This study examined retrospectively the outcome and hospital costs of one-stage versus two-stage treatment of CBD stones.MethodsFrom January 1999 and December 2014, 217 consecutive, elective patients underwent one-stage (LCBDE + LC ) or two-stage (ERCP + subsequent LC ) treatment for CBD stones. The data from the one-stage management was collected prospectively, and from the two-stage management retrospectively. The main measure of outcome was hospital costs, with the success of one-stage versus two-stage management, postoperative morbidity and postoperative stay as secondary outcome measures.ResultsOne-stage laparoscopic transcystic management was the least costly option compared to laparoscopic one-stage transductal approach (TC 5455€ versus TD 9364, p < 0.001) or two-stage management (6913 €, p = 0.02). Overall success rate of primary intervention (including conversions to open surgery) for CBD stone clearance was 96.9%, 97.0% and 98.3% after transcystic one-stage, transductal one-stage and two-stage approach, p = 0.79. Postoperative morbidity was 15.5% versus 7.5%, p = 0.64, and postoperative hospital stay median 2 days (IQR 2–5) versus 4.5 days ( IQR 3–7), p < 0.001 in the one-stage and two-stage management groups.ConclusionsOur study shows that laparoscopic one-stage transcystic management of CCL results in high rate of CBD clearance, fewer procedures per patient, shorter hospital and lower costs than the two-stage management. Therefore the one-stage transcystic management seems to be an attractive strategy for the treatment of CCL depending on local resources and surgical expertise .

Common bile duct exploration with transpapillary stenting versus T-tube drainage for management of irretrievable common bile duct stones

Background Common bile duct (CBD) stones are present in 10–18% of patients undergoing cholecystectomy for chronic calcular cholecystitis. Treatment of CBD stones is still controversial. However, CBD stones can be treated by cholecystectomy plus CBD exploration or by precholecystectomy or postcholecystectomy endoscopic retrograde cholangiopancreatography (ERCP) in two stages. If CBD exploration is performed and biliary decompression is needed after stone removal, the placement of transpapillary stent (TS) shows promising results in avoiding T-tube–related complications.Aim We aimed to evaluate the efficacy and complications of two approaches used for the management of CBD stones: intraoperative transpapillary CBD stent and T-tube external biliary drainage.Patients and methods Between May 2015 and May 2016, 24 patients underwent CBD exploration for treatment of irretrievable CBD stones. Included patients were randomly subjected to either CBD TS or T-tube drainage for management of irretrievable CBD stones after failure of ERCP.Results CBD exploration and TS placement (15 patients) was achieved either by a choledochotomy or through the cystic duct. There was no mortality in our series. Patients with a T-tube external biliary drainage (nine patients) had more surgery-related complications and a longer hospital stay. Postoperative ERCP to remove the CBD stent was successful in all cases.Conclusion Surgical transpapillary CBD stenting seems to be an effective method for management of irretrievable CBD stone with less surgical-related complications and less hospital stay and should be the first option in management of such patients.

Laparoscopic common bile duct exploration: a safe and definitive treatment for elderly patients.

Common bile duct (CBD) stone is one of the most common diseases among elderly people. In recent decades, there are numerous studies regarding the safety and efficacy of laparoscopic common bile duct exploration (LCBDE). Elderly patients are often regarded as high-risk patients because they are more likely to present with age-specific deterioration of organ function and coexisting chronic diseases, which may reduce their tolerance of laparoscopic surgery. Although laparoscopic surgery for choledocholithiasis is now widely accepted as the treatment for CBD stone, its appropriateness for the treatment of elderly patients or those with coexisting high-risk patients has not been well established. Therefore, the objective of this paper is to analyze the safety and efficacy of LCBDE in elderly patients. Between January 2012 and November 2015, 376 patients underwent LCBDE in our center. Based on their ages, they were divided into two groups, and a retrospective study was performed. By making comparisons between younger group who were younger than 70years (n=253) and elderly group who were 70years old or older (n=123), the demographics, clinical characteristics, laboratory data, operative parameters and outcomes were analyzed. Before operation, elderly patients had more coexisting chronic diseases and risk factors, such as arterial hypertension, heart diseases, pulmonary diseases and previous abdominal surgery (P<0.05). In both groups, LCBDE was equally successful with a high clearance rate (100% in elderly patients vs. 98.8% in younger group, P=0.554). Besides, the operating time, intraoperative blood loss, postoperative hospital stay, total costs and overall complication showed no significant difference between two groups (P>0.05). There was no major bile duct injury or death in either group. Although elderly patients are frequently confronted with coexisting disorders, LCBDE can be considered as a safe and effective technique in choledocholithiasis treatment for elderly patients.

Clinical analysis of endoscopic papillary muscle incision combined with balloon dilation in the treatment of common bile duct stones in elderly patients

Objective To investigate the safety and efficacy of endoscopic duodenal papillary muscle small incision(EST) combined with duodenal papillary balloon dilation(EPBD) in the treatment of elderly patients with bile duct stones. Methods 100 elderly patients with bile duct stones were treated with endoscopic stone removal.Among them, 55 patients were treated with SEST combined with EPBD(EPBD group), 45 patients were treated with a single EST(EST group), the rate of stone removal, the occurrence rate of lithotripsy and the incidence of complications were compared between the two groups. Results The SEST+ EPBD group at a time calculi clearance rate, postoperative hyperamylasemia, post pancreatitis, cholangitis were 98.2%, 7.3% and 3.6%, 1.8%, the EST group were 97.7%, 6.7%, 6.7%, 3.6% and the difference between the two groups had no significant(all P>0.05). The SEST+ EPBD group of gravel formation rate was 3.6%, lower than 13.3% in the EST group, the difference was statistically significant(χ2=9.647, P<0.05). The SEST+ EPBD group had no bleeding, bleeding in EST group incidence rate was 11.1%, the difference was statistically significant(χ2=11.235, P<0.05); The recurrence rate of the SEST+ EPBD group was 1.8%, which was lower than 11.1% in the EST group, the difference was statistically significant(χ2=10.113, P<0.05). Conclusion EST combined with EPBD in the treatment of elderly common bile duct stones is safe and effective, which can significantly reduce the incidence of debris and bleeding, reduce the recurrence rate of common bile duct stones. Key words: Duodenal papillary muscle small incision; Duodenal papillary balloon dilation; Common bile duct stones; Aged

How Does Aging Affect Presentation and Management of Biliary Stones?

Common bile duct (CBD) stones are common in elderly adults, but the effect of aging on the presentation of CBD stones remains to be evaluated. Recent studies have demonstrated that the clinical presentation of CBD stones may vary with age. Younger adults may present with classical biliary colic symptoms, whereas elderly adults may have no unapparent clinical features. Younger adults with CBD stones were significantly more likely to have abnormal liver function tests than those without. The sensitivity and accuracy of transabdominal ultrasound scans in screening for CBD stones increases with age. Antibiotic agents should be promptly administered to individuals with CBD stones complicated by cholangitis, but the effects of pharmacotherapy on renal function should be considered in elderly adults. Endoscopic retrograde cholangiopancreatography (ERCP) is considered to be first-line treatment for CBD stones, and endoscopic biliary sphincterotomy (EST) or endoscopic papillary balloon dilation (EPBD) along with ERCP is an adequate biliary drainage method in individuals with CBD stones. EPBD has a lower bleeding risk but higher post-ERCP risk of pancreatitis than EST. Longer-duration (>1 minute) EPBD may be preferred over EST because it is associated with a comparable risk of pancreatitis but a lower rate of overall complications, although recurrent cholangitis or unfavorable outcomes will increase during CBD dilation or in the presence of residual CBD stones.

Laparoscopic Management of Common Bile Duct Stones

Introduction: Common bile duct(CBD) stones are found in approximately 16% of the patients undergoing laparoscopic cholecystectomy (LC). Till recently, the gold standard for treating CBD stones wasendoscopic removal, if that failed, then open surgery. However, in the laparoscopic era, the besttreatment for CBD stones is a matter of debate and it continues to evolve. The objective of the presentstudy was to determine whether laparoscopic CBD exploration (LCBDE) is a safe, feasible and single-stageoption for the management of CBD stones. Patients and methods: All patients were done in our surgery department. Out of the 450 laparoscopiccholecystectomies between 2012-2015,we did selective intraoperative cholangiogram in 45 patients(10%) who were suspected to have CBD stones based on deranged liver function tests, dilated CBD with orwithout CBD stone on sonography or having the history of recent jaundice/ pancreatitis. If CBD stonewas found, either a transcystic or transcholedochal exploration was done depending on the size, site,number of stones and CBD diameter. Choledochotomy was closed over a t-tube in few numberof patients. Primary closure of CBD was done in the majorityof patients and in one patient we placed an antegradestent and in another one we placed endoscopic stent into the CBD laparoscpically which was removed afterfour weeks. Results: Till date we have performed LCBDE in 34 patients. Transcystic exploration wasdone in 10 patients and transcholedochal exploration was done in 20 cases out of which 2 patientshad minor biliary leak which settled on conservative treatment in 2-3 days. Four patients requiredconversion to open surgery as there were multiple stones. We did not have any major complication andon 6 months follow-up in 83.3% patients, none was found to have residual stones. Conclusion: Treatment of CBD stones depends on the resources available, technical limitations and the surgeon’sexpertise. Laparoscopic CBD exploration is a safe, feasible and single-stage option for the managementof CBD stones.

Laparoscopic CBD exploration and the long-term effect of ante-grade biliary stents

Aims: Laparoscopic common bile duct (CBD) exploration is now a standard treatment for CBD stones, however debate still remains as to whether the CBD should be closed primarily or an ante-grade biliary stent placed. A recent Cochrane review suggested further information was required regarding long-term effects of both options. This study aims to review the long-term effects of laparoscopic CBD exploration with ante-grade biliary stents. Methods: A retrospective review of all patients who underwent laparoscopic CBD exploration with biliary stent, from 2008 to 2014, by a single surgeon, was performed. The procedure was standardized and biliary stents were removed by OGD at 6 weeks post procedure. Patient demographics, co-morbidities, operative and post-operative details, along with follow-up data were collected from 2008 to date. Follow-up data included liver function tests, further imaging and procedures required. Results: 142 patients were included with a 19% (n = 27) rate of conversion. The mean age was 55.7 years, with 52 male patients. Post-operative complication rate is 9.1%, including minor bile leak (managed conservatively) 4.9%, bleeding 1.4%, fistula 0.7%, blocked stent 0.7% and wound infection 0.7%. There is a zero mortality rate. Long-term follow-up in the laparoscopic group found deranged LFTs in 10% of the group (mainly isolated GGT). 30 patients had an USS following their initial surgery, of which 80% were reported as normal. 15 patients had an MRCP - 3 had a possible stricture, none of which were confirmed at ERCP; and 6 had choledocholithiasis requiring ERCP (n = 4) or hepaticojejunostomy (n = 2). Conclusions: This study demonstrates laparoscopic CBD exploration with ante-grade biliary stent is a safe procedure with no major post-operative complications. The long-term follow-up has demonstrated no major complications associated with the use of a biliary stent, however further randomized controlled trials are required to validate this further.

Eleven years of primary closure of common bile duct after choledochotomy for choledocholithiasis.

The choice of surgical technique to extract stones from the common bile duct (CBD) depends on local experience, anatomical characteristics and also on the size, location and number of stones. Most authors consider choledochotomy an alternative to failed transcystic exploration, although some use it exclusively. Although the CBD is traditionally closed with T-tube drainage after choledochotomy, its use is associated with 11.3-27.5% morbidity. This study examined the efficacy of laparoscopic CBD exploration (LCBDE) with primary closure for the treatment of CBD stones using intraoperative cholangiography (IOC). Retrospective study of 160 patients who underwent LCBDE with primary closure after choledochotomy between January 2001 and December 2012. The diagnosis of choledocholithiasis was definitively made in all cases by IOC. The overall complication rate was 15% and the biliary complication rate was 7.5%. Bile leakage was reported in 11 patients (6.8%). In over half the cases (63.6%), no further action was required and the leak closed spontaneously. Six patients were reoperated (3.75%), two for bile peritonitis and four for haemoperitoneum. The success rate for stone clearance was 96.2%. The mortality rate and CBD stricture rate were 0%. Primary closure after choledochotomy to clear stones from the CBD is a safe technique that confers excellent results and allows one-stage treatment.

Current status of laparoendoscopic rendezvous in the treatment of cholelithiasis with concomitant choledocholithiasis.

The current evidence in favor of the laparoendoscopic rendezvous is promising and demonstrates the main advantages of this technique in regard to shorter hospital stay and selective cannulation of the common bile duct (CBD), avoiding thus the inadvertent cannulation of the pancreatic duct. In addition, in the rendezvous technique the contrast medium is not injected retrogradely as during the traditional endoscopic retrograde cholangiopancreatography (ERCP), when the medium accidentally could be injected under pressure into the pancreatic duct. The RV technique minimizes that risk. Both these main advantages of the RV technique over the classic ERCP, are related with a significant lower incidence of hyperamylasemia and post-ERCP pancreatitis, compared with the traditional two stage procedure. Choledocholithiasis is present in 10% to 15% of patients undergoing cholecystectomy. To date, the ideal management of CBD stones remains controversial. Prospective randomized trials have shown that laparoscopic management of the CBD stones, as a single stage procedure, is the most efficient and cost effective method of treatment. Laparoendoscopic rendezvous has been proposed as an alternative single stage approach. Several studies have shown the effective use of this technique in the treatment of CBD stones by improving patient compliance and clinical results including shorter hospital stay, higher success rate and less cost. The current evidence about the use of this technique presented in this review article is promising and demonstrates the main advantages of the procedure.

Risk Factors for the Presence of Residual Bile Duct Stones after Endoscopic Treatment of Stones of the Common Bile Duct

목적: 총담관담석의 내시경 제거술 이후 발생하는 잔여담석은 재발성 총담관담석으로 발현하거나 총담관담석으로자라는데 핵으로 작용할 수 있다. 그러나 관련된 위험인자에관한 연구는 드물다. 본 연구의 목적은 총담관담석의 내시경제거술 후 잔여 담석과 관련이 있는 인자들을 확인하고자하였다. 방법: 2008년 7월부터 2013년 6월까지 부산백병원에서 총담관담석으로 생애 처음 내시경 제거술을 시행 받은 환자중 잔여 담석이 발견된 환자 55명, 잔여 담석이 발견되지 않은 환자 281명을 선정하여 후향적으로 환자 대조군 연구를시행하였다. 두 군 간의 나이, 성별, 총담관담석의 성상, 혈액학적 검사 결과, 유두부 주위 게실의 유무, 기계식 쇄석술시행 유무, 유두부 풍선확장술 단독 사용 유무, 다발성 총담관담석의 동반 유무, 총담관담석의 크기, 총담관의 직경, 담낭 담석의 존재 유무, 이전에 담낭 절제술 시행 유무, 총담관담석의 내시경 제거술 시행 후 담낭 절제술 시행 여부를 비교 분석하였다. 결과: 단변량 분석에서 기계식 쇄석술을 시행 받은 경우,10 mm 이내의 유두부 풍선확장술만을 시행한 경우, 다수의총담관담석을 제거한 경우, 총담관담석의 크기가 1 cm보다큰 경우가 잔여 담석의 위험인자로 확인되었다. 다변량 분석에서 10 mm 이내의 유두부 풍선확장술만을 시행한 경우(OR, 3.174; p = 0.000), 4개 이상의 총담관담석을 제거한 경우(OR, 2.459; p = 0.013)가 잔여 담석의 발생에 관여하는 독립적인 위험인자로 확인되었다. 결론: 10 mm 크기 이내의 유두부 풍선확장술 단독 사용,4개 이상의 총담관담석이 동반된 경우가 총담관담석의 내시경 제거술 후 잔여 담석의 발생과 관련된 독립된 위험인자이고 이런 인자들이 동반된 환자의 시술 시 더욱 주의를 기울임과 동시에 2차 내시경 역행 담췌관조영술을 고려해야하겠다.

Reappraisal of endoscopic papillary balloon dilation for the management of common bile duct stones.

Although endoscopic sphincterotomy (EST) is still considered as a gold standard treatment for common bile duct (CBD) stones in western guideline, endoscopic papillary balloon dilation (EPBD) is commonly used by the endoscopists in Asia as the first-line treatment for CBD stones. Besides the advantages of a technical easy procedure, endoscopic papillary large balloon dilation (EPLBD) can facilitate the removal of large CBD stones. The indication of EPBD is now extended from removal of the small stones by using traditional balloon, to removal of large stones and avoidance of lithotripsy by using large balloon alone or after EST. According to the reports of antegrade papillary balloon dilatation, balloon dilation itself is not the cause of pancreatitis. On the contrary, adequate dilation of papillary orifice can reduce the trauma to the papilla and pancreas by the basket or lithotripter during the procedure of stone extraction. EPLBD alone is as effective as EPLBD with limited EST. Longer ballooning time may be beneficial in EPLBD alone to achieve adequate loosening of papillary orifice. The longer ballooning time does not increase the risk of pancreatitis but may reduce the bleeding episodes in patients with coagulopathy. Slowly inflation of the balloon, but not exceed the diameter of bile duct and tolerance of the patients are important to prevent the complication of perforation. EPBLD alone or with EST are not the sphincter preserved procedures, regular follow up is necessary for early detection and management of CBD stones recurrence.

Intraductal ultrasonography-directed endoscopic retrograde biliary drainage without fluoroscopy.

Common bile duct (CBD) stones may cause septic shock and lead to life-threatening conditions [1]. Endoscopic sphincterotomy (EST) and stone removal is an accepted method for the treatment of CBD stones [2]. EST has the potential to cause bleeding in patients with a bleeding risk. However, endoscopic retrograde biliary drainage (ERBD) can be performed effectively and safely without EST in these patients. ERBD has been performed under fluoroscopy, resulting in a relatively long duration of radiation exposure [3] [4]. Intraductal ultrasound (IDUS) provides real-time cross-sectional imaging within the bile duct. IDUS can be performed without fluoroscopy. Therefore, IDUS-directed ERBD can be used to reduce the time of radiation exposure for both examiners and patients. This report describes IDUS-directed ERBD with a plastic stent without fluoroscopy in patients with a risk of bleeding.

ERCP in Management of Common Bile Duct Stones in Children: Safety and Efficacy

Background and study aim: Choledo-cholithiasis due to common bile duct (CBD) stones is a critical condition in children. The aim of this study was to evaluate the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in management of CBD stones in children. Patients and methods: Twenty five children suffering from obstructive jaundice were diagnosed and selected after completion of full laboratory and radiological investigations in the period from June 2010 till December 2013 and were admitted to the Surgery Department Zagazig University Hospitals, Egypt. Patients were classified into 2 age groups below and above 6 years to decide the diameter of ERCP scope and the stents used in the procedure. Group A; 0-6 years were 12 patients and Group B; 6-15 years were 13 patients. Results : ERCP was adequate in helping to predict biliary ductal stones and removal of them in all patients with no reported diagnostic or therapeutic failure. The stent placement was indicated in 21 of the 25 (84%) children, the other 4 children (16%) just sludge was cleared using basket forceps without the need for stent insertion. Two to three weeks later laparoscopic chole-cystectomy was successfully performed to all indicated children with removal of the stent after 2 to 3 weeks. There rate of ERCP complications was 12% (3 cases), one case reported mild pancreatitis and 2 cases reported mild cholagnitis. Conclusion : The encouraging results of this study with very minimal insignificant complications of ERCP (safety) and good results of ERCP in treatment of CBD stones in children (efficacy) recommend that children with choledocholithiasis due to CBD stone or sludge should be treated by endoscopic CBD stone or sludge removal

Balloon dilation itself may not be a major determinant of post-endoscopic retrograde cholangiopancreatography pancreatitis.

Endoscopic retrograde cholangiopancreatography (ERCP) is the essential first modality for common bile duct (CBD) stone therapy. The conventional endoscopic treatment for CBD stones is stone removal after endoscopic sphincterotomy (EST). Stone removal after papillary stretching using balloon dilation instead of the conventional method has been widely adopted. There are many reports regarding endoscopic papillary balloon dilation (EPBD) utilizing a small balloon (< 10 mm) instead of EST for the removal of small CBD stones. In contrast, two cases of mortality due to post-ERCP pancreatitis (PEP) were reported after an EPBD clinical trial in the Western world, and the psychological barrier caused by these incidences hinders the use of this technique in Western countries. Endoscopic papillar large balloon dilation (EPLBD), which is used to treat large CBD stones, was not widely adopted when first introduced due to concerns about perforation and severe pancreatitis from the use of a large balloon (12-20 mm). However, as experience with this procedure accumulates, the occurrence of PEP with EPLBD is confirmed to be much lower than with EPBD. This report reviews whether EPBD and EPLBD, two procedures that use balloon dilation but differ in terms of indications and concept, contribute to the occurrence of PEP.

A Laparoscopic Approach to CBD Stones

: This study aimed to evaluate single-stage surgical (laparoscopic or open) approach to the management of common bile duct (CBD) stones, as treatment of choice. Prospectively collected data to assess outcomes of CBD clearance, morbidity, mortality, and hospital stay, and compared with published data. Successful clearance of CBD stones was achieved in 96% cases, laparoscopic exploration successful in 83%. Retained stones were found in 4% cases and another 5% developed postoperative complications. Common length of stay in hospital was 2 days, although mean stay was 4 days. Seventy-three percent of cases were elective, 27% were emergencies. Conversion rate to open surgery was 14%, which was mainly in emergency cases. Postoperative mortality was 1.2%, not directly related to the procedure. Good outcomes can be achieved, comparing favorably with those of other modalities, when laparoscopic bile duct exploration is chosen as treatment for CBD stones; the best results can be anticipated in elective patients.

Dilation-Assisted Stone Extraction: An Alternative Method for Removal of Common Bile Duct Stones

Dilation-assisted stone extraction, also termed small endoscopic sphincterotomy (EST) plus endoscopic papillary balloon dilatation, is more efficient than EST alone for removal of large common bile duct (CBD) stones. However, whether this technique can be used for all stones is unclear. This study was designed to evaluate the efficacy and complications of dilation-assisted stone extraction for CBD stones. A total of 462 patients with CBD stones were randomized to undergo either dilation-assisted stone extraction (group A) or EST (group B). The efficacy and complications of the two techniques were compared. Groups A and B showed similar outcomes in terms of stone removal. The short-term and 1-year complication rates were also similar between the two groups. However, the first-session stone removal rate in group A was significantly higher than that in group B. Mechanical lithotripsy was required significantly more often in group B than in group A. The total procedure time and total fluoroscopy time in group A were significantly shorter than those in group B. Dilation-assisted stone extraction and EST are safe and effective techniques for the treatment of CBD stones. Dilation-assisted stone extraction has high efficiency. This technique is an alternative method for removal of CBD stones.

Endoscopic Papillary Large-Balloon Dilatation in Patients with Billroth II Gastrectomy

Endoscopic sphincterotomy (ES), introduced by Classen et al. [1] as a minimally invasive technique to retrieve common bile duct (CBD) stones in high-surgical-risk patients, has become the foundation of endoscopic therapy for patients with biliary disease, with a *90 % rate of successfully removing CBD stones with basket extraction or balloon sweeping. As an alternative to ES, Staritz et al. [2] described in 1983 endoscopic papillary balloon dilatation (EPBD) with the aim of avoiding complications associated with ES in the short term such as pancreatitis, perforation, bleeding, and infection, or in the long term such as papillary stenosis and bacterial biliary contamination. EPBD is effective for the treatment of CBD stones with retrieval rates of 80–100 % [3]. The efficacy of ES and EPBD in the removal of CBD stones has been compared with multiple prospective studies and with at least two recent meta-analyses [4, 5], which have concluded that EPBD is associated with lower rates of bleeding and perforation than ES [3–6] but with a higher rate of pancreatitis [4, 5, 7, 8]. Moreover, EPBD is also associated with a lower retrieval rate of CBD stones [4, 5] which, combined with higher rates of pancreatitis, are the main reasons why most endoscopists choose ES over EPBD for CBD stone extraction. Thus, EPBD has become second line, mainly used for endoscopic treatment of CBD stones in patients with liver cirrhosis or coagulopathy. Ten years ago, one single-center retrospective study reported that ES followed by endoscopic papillary largeballoon dilation (EPLBD) of the papillary orifice (10–20 mm) improved the extraction rate of large CBD stones [9]. Further studies confirmed that ES followed by EPLBD is an effective and safe technique for retrieving large CBD stones after failure of common extraction techniques using balloon or basket [10–12]. EPLBD performed after ES effectively removed up to 87–95 % of large CBD stones in patients after the failure of balloon or basket extraction attempts [9–11]. EPLBD could also minimize the chances of pancreatitis since the existing sphincterotomy enables the dilation to proceed upward rather than circumferentially [10]. The most common complication described with this technique is bleeding that occurs in 8.3 % of patients. EPLBD after ES has also been successfully used for extraction of large CBD stones in patients with Billroth II gastrectomy [13]. ES in Billroth II gastrectomy patients is more difficult than in patients with normal anatomy due to the need for the inverted papillary approach despite the development of specific sphincterotomes. Thus, EPBD may be particularly suited for Billroth II gastrectomy patients, although the previously mentioned limitations restrict its utility. Since EPLBD alone is effective and safe in patients with normal anatomy [14], performing EPLBD without previous ES in patients with Billroth II gastrectomy is the next challenge. The outcomes of this procedure in 40 patients are described in this issue of Digestive Diseases and Sciences [15]. Jang et al. performed EPLBD alone to treat patients following Billroth II gastrectomy with difficult-toextract CBD stones. Fourteen patients with four or more J. J. Vila Endoscopy Unit, Complejo Hospitalario de Navarra, Pamplona, Spain e-mail: juanjvila@gmail.com

Intraoperative Endoscopist-Controlled Guide Wire Cannulation Technique Sphincterotomy During Laparoscopic Cholecystectomy

Intraoperative endoscopic sphincterotomy (IOES) is considered superior to preoperative endoscopic sphincterotomy and other treatment modalities for management of common bile duct (CBD) stones. Here we describe the method and results of our technique of IOES in the supine position during laparoscopic cholecystectomy (LC) using a guide wire cannulation (intraoperative supine endoscopic sphincterotomy by endoscopist-controlled guide wire cannulation) [ISEEG] technique). This is a retrospective analysis of the outcome for 36 patients undergoing LC with IOES (ISEEG technique) for acute biliary colic and jaundice with suspicion of choledocholithiasis. On confirmation of CBD stones by intraoperative cholangiogram, CBD catheterization was successful in 34/36 (94.44%) patients with successful stone clearance in all of them by the ISEEG technique demonstrating 100% efficacy for stone clearance; the remaining 2 patients needed conversion to open surgery. The median time for the ISEEG technique during intraoperative sphincterotomy was 9 minutes (range, 7-23 minutes). Average hospital stay was 4.8 days (range, 2-15 days). At the 1-month follow-up, all patients were biliary symptom-free. Three of 36 patients (8.33%) had mild postoperative pancreatitis. There was no procedure-related mortality. LC coupled with the ISEEG technique performed by an expert endoscopist is an effective single-stage minimally invasive treatment for CBD stones with good efficacy, good stone clearance rates, and low morbidity.

PWE-156 Common bile duct stones; a surgical disease

IntroductionThere is no clear consensus, from previous randomised controlled trials and meta-analyses, on the optimum treatment modality for common bile duct (CBD) stones. This study aimed to evaluate the single-stage...

Two-Port Laparoscopic Common Bile Duct Exploration with T-tube Choledochostomy for Management of Choledocholithiasis: An Initial Clinical Report

Laparoscopic common bile duct exploration (LCBDE) is generally performed using a four- or five-port technique. We report a unique technique of two-port transcholedochal LCBDE with T-tube placement. Twelve consecutive patients with common bile duct (CBD) stones underwent LCBDE through two entry ports, one homemade single port (Uen port) inserted in a 2-cm umbilical wound and one 5-mm subxiphoid trocar port. With the assistance of a 1.2-mm needle that was inserted through a right lower intercostal space into the abdominal cavity to facilitate the operation, two-port dome-down laparoscopic cholecystectomy, choledochotomy, choledochoscopic removal of ductal caculi, and T-tube choldochostomy were performed with conventional methods using standard laparoscopic instruments along with manually operated angled shafts. After completion of the operation, the T-tube catheter was brought out through the subxiphoid trocar wound. All operations were completed successfully without the need of additional ports. There was no complication and no residual stones. Mean operation time was 120 minutes (range, 90 to 150 minutes), and mean postoperative hospital stay was 3.5 days (range, 3 to 4 days). Scarless wound healing was achieved except one T-tube scar. Two-port transumbilical LCBDE with T-tube choledochostomy is a feasible, safe, and effective technique that allows one-scar abdominal surgery for treatment of CBD stones. Further studies and the development of better instruments are necessary before this can be recommended as a standard procedure.