scholarly journals O-BN06 A Proposed Difficulty Grading System for Laparoscopic Bile Duct Exploration. Benefits to Practice and Research

2021 ◽  
Vol 108 (Supplement_9) ◽  
Author(s):  
Mahmoud Sallam ◽  
Ahmad H M Nassar ◽  
Rhona Kilpatrick ◽  
Kiren Ali
Keyword(s):  
Bile Duct ◽  
Emergency Admission ◽  
Consecutive Series ◽  
Bile Duct Stones ◽  
Single Session ◽  
Bilioenteric Anastomosis ◽  
Intrahepatic Stones ◽  
Session Management ◽  
Grade Classification ◽  
Laparoscopic Bile Duct Exploration

Abstract Background A gap remains between the mounting evidence for single session management of bile duct stones and the obstacles to wider adoption of this approach. The practice of laparoscopic bile duct exploration (LCBDE) is limited not only by the availability of training opportunities and adequate equipment but also by the perception that the technique is difficult and requires a high skill-set. The aim of this analysis is to compare the preoperative and operative characteristics and the postoperative outcomes in easy vs. difficult LCBDE in a large consecutive series, according to a proposed 5 grade classification. Methods 1326 LCBDEs were graded according to the location, number and size of ductal stones, retrieval techniques used, utilisation of choledochoscopy and specific biliary pathologies encountered. The cohort was divided into two groups: easy (Grades I A&B, and Grade II A&B, requiring transcystic or transductal exploration for up to 15 stones the largest being 15mm) and difficult (Grades III A&B, for over 15 stones or intrahepatic stones of any size needing transcystic choledochoscopy, IV and V with Mirizzi Syndrome, impacted stones, and ducts needing stenting, conversion or bilioenteric anastomosis). Various outcome parameters were compared. Results Age, sex, obesity and previous biliary admissions had no effect on operative difficulty. Emergency admission, obstructive jaundice, previous ERCP and dilated CBD were predictive of difficult explorations. 78.3% of patients with acute cholecystitis or pancreatitis, 37 % of jaundice and 46% of cholangitis had easy explorations. Transcystic stone retrieval was possible in 77.7% of easy explorations and choledochotomy required in 62.3% of difficult explorations (vs. 33.6% in the whole series). Choledochoscopy was utilised in 23.4% of Grades I&II vs. 98% in difficult explorations. As expected more biliary drains, stenting, bilio-enteric anastomosis, conversions, operative time, biliary-related complications, hospital stay, readmissions and retained stones increased with difficulty. Grades I&II patients had 2 or more hospital episodes in 26.5% vs. 41.2% for grades III to V, the median presentation to resolution interval increasing from 1 to 3 weeks. There were 2 deaths in difficulty Grade V and one in Grade IIB. Conclusions Difficulty grading of LCBDE is a useful tool of predicting outcomes. It facilitates comparison between studies and fair assessment of training. LCBDEs are easy in 72% and of these 77% can be completed transcystically. It is hoped this will encourage more units to adopt single session management of bile duct stones through establishing referral protocols, developing and refining the skills through training and acquiring the necessary equipment.

scholarly journals Endoscopic laser lithotripsy for complicated bile duct stones: is cholangioscopic guidance necessary?

2007 ◽  
Vol 44 (2) ◽  
pp. 137-140 ◽  
Author(s):  
Ralf Jakobs ◽  
Julio C. Pereira-Lima ◽  
Aline W. Schuch ◽  
Lucas F. Pereira-Lima ◽  
Axel Eickhoff ◽  
...  
Keyword(s):  
Bile Duct ◽  
Laser Lithotripsy ◽  
Bile Duct Stones ◽  
Distal Bile Duct ◽  
Laser Guidance ◽  
Endoscopic Papillotomy ◽  
Intrahepatic Stones ◽  
Bile Duct Stenosis ◽  
Extracorporeal Shock Wave ◽  
Fluoroscopic Control

BACKGROUND: Endoscopic papillotomy is successful in more than 95% of the cases of choledocholithiasis. For patients with difficult bile duct stones not responding to mechanical lithotripsy, different methods for stone fragmentation have been developed. AIM: To compare the results of laser lithotripsy with a stone-tissue recognizing system, when guided by fluoroscopy only or by cholangioscopy. METHODS: Between 1992 and 2002 we have treated 89 patients with difficult bile duct stones by endoscopic retrograde cholangiopancreatography and laser lithotripsy. Unsuccessful extracorporeal shock-wave lithotripsy and electrohydraulic were also performed before laser in 35% and 26% of the cases, respectively. RESULTS: Laser was effective in 79.2% of 72 patients guided by cholangioscopy and in 82.4% of 17 cases steered by fluoroscopy. The median number of impulses in the latter was 4,335 and 1,800 with the former technique. Two parameters influenced the manner of laser guidance. In cases of stones situated above a stricture, cholangioscopic control was more effective (64.7% vs. 31.9%). When the stones were in the distal bile duct, fluoroscopic control was more successful. CONCLUSION: In cases of difficult stones in the distal bile duct, laser lithotripsy under fluoroscopic control is very effective and easily performed. Cholangioscopic guidance should be recommended just in cases of intrahepatic stones or in patients with stones situated proximal to a bile duct stenosis. In these cases, cholangioscopy should be performed either endoscopically or percutaneously.

scholarly journals Liver Resection for Intrahepatic Stones

HPB Surgery ◽  
1990 ◽  
Vol 2 (2) ◽  
pp. 145-147 ◽  
Author(s):  
Roland Andersson ◽  
Karl-Göran Tranberg ◽  
Stig Beng-Mark
Keyword(s):  
Liver Resection ◽  
Bile Duct ◽  
Intrahepatic Bile Duct ◽  
Liver Parenchyma ◽  
Long Term Results ◽  
Bile Duct Stricture ◽  
Bile Duct Stones ◽  
Intrahepatic Stones ◽  
Duct Stricture

Intrahepatic stones are difficult to manage, especially when they are associated with bile duct stricture, cholangitis and destruction of liver parenchyma. Suggested modes of treatment include surgical bile duct exploration, endoscopic procedures, transhepatic cholangiolithotomy and liver resection. This paper reports 2 patients in whom liver resection was performed because of intrahepatic ductal stones, bile duct strictures and repeated episodes of cholangitis. Liver resection was uncomplicated and long-term results were satisfactory. Our results support the view that liver resection is indicated in rare instances of intrahepatic bile duct stones associated with bile duct strictures.

scholarly journals O-EGS05 The Prevalence of Bile Duct Stones in Patients Presenting with Acute Pancreatitis vs. Jaundice in a 5774 patient series. The Case for Single Session Surgical Management

2021 ◽  
Vol 108 (Supplement_9) ◽  
Author(s):  
Ahmad H m Nassar ◽  
Rhona Kilpatrick ◽  
Mahmoud Sallam ◽  
Kiren Ali
Keyword(s):  
Acute Pancreatitis ◽  
Surgical Treatment ◽  
Bile Duct ◽  
Hospital Stay ◽  
Surgical Management ◽  
Index Admission ◽  
Management Approach ◽  
Bile Duct Stones ◽  
Single Session ◽  
Cbd Stones

Abstract Background There is increasing evidence that single session laparoscopic cholecystectomy with cholangiography and, when necessary and available, bile duct exploration offers optimal clinical outcomes and superior cost benefits to patients with suspected bile duct stones. There is a perception that preoperative endoscopic clearance of bile duct stones is necessary in patients presenting with pancreatitis and jaundice. However, most patients do not have severe disease and are fit for index admission surgical management. We aim to study the prevalence of bile duct stones in pancreatitis vs. jaundice and evaluate this management approach with regards to preoperative and operative parameters and postoperative outcomes. Methods Analysis of prospectively maintained database of 5774 consecutive laparoscopic cholecystectomies, cholangiography(IOC) with or without bile duct exploration was undertaken. Patients with suspected bile duct stones are referred to one firm with an intention of single surgical treatment in the index admission. Data of patients presenting with acute pancreatitis and obstructive jaundice was extracted. In the absence of suspected malignancy there was a limited role for preoperative MRCP and ERCP. The incidence of confirmed CBD stones requiring exploration, type of exploration, morbidity, re-operations and readmissions, hospital stay, number of episodes, and presentation to resolution intervals were compared in the two groups. Results Conclusions Single session surgical treatment of patients with acute pancreatitis and jaundice by specialist firms in the index admission (89% and 86% if previous admissions by other units is excluded) offers many advantages. MRCP and ERCP utilisation is minimised in favour of IOC; two thirds of pancreatitis patients and one third of jaundiced patients have no CBD stones. Simple transcystic explorations deals with most stones in both groups. The morbidity, open conversion, readmissions, retained stones and re-operations are low. Total hospital stay, number of treatment episodes and presentation to resolution are optimised and should persuade surgeons to avoid subjecting patients to multiple treatments.

Cholangioscopy-guided lithotripsy for difficult bile duct stone clearance in a single session of ERCP: results from a large multinational registry demonstrate high success rates

Endoscopy ◽  
2019 ◽  
Vol 51 (10) ◽  
pp. 922-929 ◽  
Author(s):  
Amit P. Maydeo ◽  
Rungsun Rerknimitr ◽  
James Y. Lau ◽  
Abdulrahman Aljebreen ◽  
Saad K. Niaz ◽  
...  
Keyword(s):  
Bile Duct ◽  
Bile Duct Stone ◽  
Hepatic Duct ◽  
Laser Lithotripsy ◽  
Bile Duct Stones ◽  
Success Rates ◽  
Single Session ◽  
Serious Adverse Events ◽  
Stone Clearance ◽  
First Line Therapy

Abstract Background Peroral cholangioscopy (POCS) can be useful for difficult bile duct stone clearance. Large prospective multinational data on POCS-guided lithotripsy for clearing difficult bile duct stones in a single session of endoscopic retrograde cholangiopancreatography (ERCP) are missing. Methods Patients with difficult bile duct stones (defined as one or more of: largest stone diameter ≥ 15 mm, failed prior attempt at stone clearance, impacted, multiple, hepatic duct location, or located above a stricture) were enrolled at 17 centers in 10 countries. The principal endpoint was stone clearance in a single ERCP procedure using POCS. Results 156 patients underwent 174 sessions of POCS-guided electrohydraulic or laser lithotripsy. Stone clearance had failed in a previous ERCP using traditional techniques in 124/156 patients (80 %), while 32 /156 patients (21 %) were referred directly to POCS-guided therapy based on preprocedural assessment of the difficulty of stone clearance. In 101/156 patients (65 %), there were impacted stones. POCS-guided stone clearance was achieved in a single POCS procedure in 125 /156 patients (80 %, 95 % confidence interval [CI] 73 % – 86 %), and was significantly more likely for stones ≤ 30 mm compared with > 30 mm (odds ratio 7.9, 95 %CI 2.4 – 26.2; P = 0.002). Serious adverse events occurred in 3/156 patients (1.9 %, 95 %CI 0.4 % – 5.5 %), and included pancreatitis, perforation due to laser lithotripsy, and cholangitis (n = 1 each), all resolved within 1 week. Conclusion POCS-guided lithotripsy is highly effective for clearance of difficult bile duct stones in a single procedure and successfully salvages most prior treatment failures. It may also be considered first-line therapy for patients with difficult choledocholithiasis to avoid serial procedures.

scholarly journals Review Article: Spectrum of Biliary Infections in the West and in the East

HPB Surgery ◽  
1995 ◽  
Vol 8 (4) ◽  
pp. 215-222 ◽  
Author(s):  
H. G. Beger ◽  
A. Schwarz
Keyword(s):  
Bile Duct ◽  
Common Bile Duct ◽  
Elderly Population ◽  
Common Bile Duct Stones ◽  
Western World ◽  
Bile Pigment ◽  
Bile Duct Stones ◽  
The West ◽  
Intrahepatic Stones ◽  
Male To Female

Biliary infections are an important cause of morbidity in the Western world. With regard to epidemiology, etiology, microbiological spectrum, prevalence, location and composition of gallstones, pathogenesis, clinical sign and therapy, there are large differences between the spectrum of biliary infections in the East and in the West (Table 1). In Western countries, gallstones are found in 10 to 40%. In Eastern countries, the incidence of gallstones is only 2 to 6%. Some eighty – five percent of the gallstones in the West are cholesterol stones, in contrast to the East, where 97% are bile pigment stones. The most important difference is characterized by the origin of common bile duct stones. In the West, common bile duct stones generally originate in the gallbladder, in contrast to the East, where primary common bile duct stones are often found – especially in the intrahepatic segments – with no evidence of gallbladder stones. The sex distribution male to female in the West is 1:2, in the East 1:1. In the West, biliary infections occur mainly in an elderly population, 50% being older than 70 years. In the East, biliary infections appear also in younger people, 50% being younger than 40 years. Parasites play an aetiological role in the East, but not in the West. The typical therapy of gallstones in the West is cholecystectomy, and of common bile duct stones endoscopic sphincterotomy. Due to the frequency of intrahepatic stones in Eastern Countries, the therapeutic spectrum there includes even large hepatic resections and biliary enteric anastomoses.

scholarly journals Open bile duct exploration as a therapeutic solution for difficult to manage choledocholithiasis: a case report

2021 ◽  
Author(s):  
Eduardo Poblano Olivares ◽  
Brenda Soto Perez ◽  
Jorge L. Olmos Gonzalez
Keyword(s):  
Bile Duct ◽  
Bile Ducts ◽  
Clinical Suspicion ◽  
Minimally Invasive Procedures ◽  
Bile Duct Stones ◽  
Invasive Procedures ◽  
Duct Obstruction ◽  
Intrahepatic Stones ◽  
Common Etiology ◽  
Therapeutic Alternatives

The most common etiology of bile duct obstruction in patients with cholelithiasis is choledocholithiasis. The diagnosis of cholelithiasis is based on clinical suspicion and confirmed by ultrasound (US) of the liver and bile ducts. The management of bile duct lithiasis has evolved considerably and currently, ERCP is the most common and recommended technique. However, in cases of multiple lithiases, fragmentation of the lithiasis during extraction, excessive preoperative or transoperative handling of the ampullary region, previous stenosis of the ampullary region, juxtapapillary diverticula, primary bile duct stones, or residual intrahepatic stones, a large number of hospitals do not have sufficient resources to perform minimally invasive procedures and offer these therapeutic alternatives instead.  

Gallstone disease

2018 ◽  
pp. 401-414
Author(s):  
Abdullah Jibawi ◽  
Mohamed Baguneid ◽  
Arnab Bhowmick
Keyword(s):  
Laparoscopic Cholecystectomy ◽  
Bile Duct ◽  
Obstructive Jaundice ◽  
Gallstone Disease ◽  
Acute Cholangitis ◽  
Biliary Colic ◽  
Ultrasound Scan ◽  
Bile Duct Stones ◽  
Clinical Presentations ◽  
Laparoscopic Bile Duct Exploration

Gallstone disease is common with clinical presentations including biliary colic, cholecystitis, and obstructive jaundice. Acute cholangitis and pancreatitis are other complications. Ultrasound scan and MRCP as well as endoscopic ultrasound are investigation modalities. Medical treatment of gallstones with ursodeoxycholic acid is discussed as well as laparoscopic cholecystectomy with its risks and benefits. The prevalence of bile duct stones is around 10–20%. Strategies for investigation and management are discussed, including ERCP and laparoscopic bile duct exploration.

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