Management of CBD stones in patients having laparoscopic cholecystectomy in a private setting in Australia

Background: Cholelithiasis is a common disease and at present the laparoscopic cholecystectomy is the gold standard treatment. The diagnosis of associated common bile duct stone for patients with gallstones is important for prompt surgical decision, treatment efficacy and patient safety. However, whether upper abdominal ultrasound and Liver function test (LFT) is adequate before doing lap cholecystectomy remains controversial. There are different opinions regarding the routine magnetic resonance cholangiopancreatography (MRCP) to detect the possible presence of common bile duct (CBD) stones before laparoscopic cholecystectomy.Methods: This study was carried on a total of 106 patients who were admitted and treated for gall stone diseases in the Department of General Surgery, GSL General Hospital over a period of 24 months. After admission all cases were subjected for liver function test, USG abdomen and MRCP. The collected observational data was analyzed.Results: Among the 106 patients, a total of 17cases showed concurrent gallstones and choledocholithiasis, 11 cases choledocholithiasis were revealed by ultrasound examination, while 6 cases of choledocholithiasis were not detected by ultrasound examination but were confirmed by MRCP.Conclusions: CBD stone may be missed even in the presence of deranged liver enzymes or dilated CBD in USG abdomen. Hence for patient safety routine preoperative MRCP examination is recommended before doing laparoscopic cholecystectomy to rule out the likelihood of concomitant CBD stones. The cost-effectiveness of such expensive investigation is to be studied further taking into consideration preventive costs and patient morbidity and mortality.

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Management in single stage of the common bile duct (CBD) stones: laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiopancreatography (ERCP) versus surgery for CBD stones

HPB ◽

10.1016/j.hpb.2016.01.024 ◽

2016 ◽

Vol 18 ◽

pp. e671-e672 ◽

Cited By ~ 1

Author(s):

E. Chapuis-Roux ◽

J.C. Berthou ◽

L. Pellissier ◽

F. Browet ◽

R. Delcenserie ◽

...

Keyword(s):

Laparoscopic Cholecystectomy ◽

Bile Duct ◽

Common Bile Duct ◽

Endoscopic Retrograde Cholangiopancreatography ◽

Single Stage ◽

Endoscopic Retrograde ◽

Cbd Stones ◽

The Common

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Laparoscopic Common Bile Duct Exploration for Choledocholithiasis During a Pregnancy: a Case Report

Acta Chirurgica Latviensis ◽

10.1515/chilat-2016-0017 ◽

2016 ◽

Vol 16 (1) ◽

pp. 41-43 ◽

Cited By ~ 1

Author(s):

Janis Lacis ◽

Ieva Rancane ◽

Haralds Plaudis ◽

Evita Saukane ◽

Guntars Pupelis

Keyword(s):

Laparoscopic Cholecystectomy ◽

Bile Duct ◽

Common Bile Duct ◽

Gallstone Disease ◽

Intraoperative Ultrasound ◽

Common Bile Duct Exploration ◽

Dynamic Imaging ◽

Gallbladder Motility ◽

Cbd Stones ◽

Nulliparous Women

SummaryIn population studies, gallstones are found in 6.5% to 8.4% of nulliparous women, and in 18.4% to 19.3% of women with two to three or more pregnancies (7). Approximately 1 in 500 to 1 in 635 women will require non-obstetrical abdominal surgery during their pregnancies. Pregnancy induced physiological hormonal changes are associated with a decrease of gallbladder motility and increased cholesterol saturation of bile, leading to biliary stone formation (12,6,8). Surgical approach nowadays is the method of choice in the management of symptomatic gallstone disease during pregnancy, preferably if possible surgery should be postponed to second trimester (7,8).Preoperative radiologic imaging using magnetic resonance cholangiopancreatography is the golden standard for patients with suspected choledocholithiasis, however, its application during pregnancy is limited (9). Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) may be used before, during or after laparoscopic cholecystectomy when it is indicated, but unfortunately, its application during pregnancy is associated with considerable number of complications concerning mother and fetus. Alternative approach has been developed and recommended for patients with the common bile duct (CBD) stones providing laparoscopic common bile duct exploration (LCBDE). Intraoperative cholangiography or intraoperative ultrasound (IOUS) are the methods currently used for detection of the CBD stones during laparoscopic cholecystectomy, however, IOUS can be considered as the method of choice during pregnancy (3).IOUS is a dynamic imaging modality that provides interactive and timely information during surgical procedures. Because the transducer is in direct contact with the organ being examined, high-resolution images can be obtained that are not degraded by air, bone, or overlying soft tissue (1).

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SP6.1.6 Rule of systematic intraoperative cholangiogram in patients undergoing emergency cholecystectomy

British Journal of Surgery ◽

10.1093/bjs/znab361.133 ◽

2021 ◽

Vol 108 (Supplement_7) ◽

Author(s):

Fady Hatem ◽

Sam Mostafa ◽

Jenny Thomas ◽

Ahmad Nassar

Keyword(s):

Laparoscopic Cholecystectomy ◽

Cystic Duct ◽

Gall Stone ◽

Stone Disease ◽

Cbd Stones ◽

Gall Stones ◽

Gall Stone Disease ◽

Biliary Ducts ◽

Emergency Cholecystectomy

Abstract Aims Incidence of gall stone disease is estimated at 10-15%of population. Intraoperative cholangiography (IOC) diagnose choledocholithiasis, delineates the anatomy of the biliary ducts, facilitate the dissection and reduces injuries. Our aim is to assess the feasibility and role of IOC and the incidence of choledocholithiasis in acute cholecystitis (ACC). Methods Retrospective analysis of prospectively collected data for patients admitted with ACC and undergoing same-hospital-stay laparoscopic cholecystectomy (LC). IOC was systematically attempted in all cases. Results 475cases included. Female to male ratio1.9:1. Conversion to open was done in 3 cases. Preoperative cholelithiasis was confirmed in 439cases versus 34cases with no stones. USS CBD abnormality (dilated or contain stone) found in 53 cases, out of which 8(15%) cases had CBD stones. Jaundice was found in 69cases, where 25(39%) cases had confirmed choledocholithiasis. IOC was successful in all cases except one. Abnormal IOC was found in 99(21%) cases. Of those; CBD stones were confirmed in 76 (77%) cases regardless the presence of cholelithisasis on USS. Empyema was found in 237 cases and it was associated with higher risk of abnormal IOC in 59(25%) cases where CBD stones were confirmed in 45(76%) cases. Cystic duct (CD) stones found in 80cases, of those 27(34%)cases had choledocholithiasis. Conclusions Females have double the risk of ACC. Preoperative jaundice and CD stones are stronger indicators than CBD diameter for presence of choledocholithiasis. The incidence of choledocholithiasis in ACC is (20-25%) regardless the presence of gall stones on USS. IOC is feasible and highly recommended in emergency LC.

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Randomised controlled trial to establish the clinical and cost-effectiveness of expectant management versus preoperative imaging with magnetic resonance cholangiopancreatography in patients with symptomatic gallbladder disease undergoing laparoscopic cholecystectomy at low or moderate risk of common bile duct stones (The Sunflower Study): a study protocol

BMJ Open ◽

10.1136/bmjopen-2020-044281 ◽

2021 ◽

Vol 11 (6) ◽

pp. e044281

Author(s):

Madeleine Clout ◽

Jane Blazeby ◽

Chris Rogers ◽

Barnaby Reeves ◽

Michelle Lazaroo ◽

...

Keyword(s):

Laparoscopic Cholecystectomy ◽

Cost Effectiveness ◽

Controlled Trial ◽

Gallbladder Disease ◽

Expectant Management ◽

Magnetic Resonance Cholangiopancreatography ◽

Preoperative Imaging ◽

Moderate Risk ◽

Cbd Stones ◽

Randomised Controlled

IntroductionSurgery to remove the gallbladder (laparoscopic cholecystectomy (LC)) is the standard treatment for symptomatic gallbladder disease. One potential complication of gallbladder disease is that gallstones can pass into the common bile duct (CBD) where they may remain dormant, pass spontaneously into the bowel or cause problems such as obstructive jaundice or pancreatitis. Patients requiring LC are assessed preoperatively for their risk of CBD stones using liver function tests and imaging. If the risk is high, guidelines recommend further investigation and treatment. Further investigation of patients at low or moderate risk of CBD stones is not standardised, and the practice of imaging the CBD using magnetic resonance cholangiopancreatography (MRCP) in these patients varies across the UK. The consequences of these decisions may lead to overtreatment or undertreatment of patients.Methods and analysisWe are conducting a UK multicentre, pragmatic, open, randomised controlled trial with internal pilot phase to compare the effectiveness and cost-effectiveness of preoperative imaging with MRCP versus expectant management (ie, no preoperative imaging) in adult patients with symptomatic gallbladder disease undergoing urgent or elective LC who are at low or moderate risk of CBD stones. We aim to recruit 13 680 patients over 48 months. The primary outcome is any hospital admission within 18 months of randomisation for a complication of gallstones. This includes complications of endoscopic retrograde cholangiopancreatography for the treatment of gallstones and complications of LC. This will be determined using routine data sources, for example, National Health Service Digital Hospital Episode Statistics for participants in England. Secondary outcomes include cost-effectiveness and patient-reported quality of life, with participants followed up for a median of 18 months.Ethics and disseminationThis study received approval from Yorkshire & The Humber – South Yorkshire Research Ethics Committee. Results will be submitted for publication in a peer-reviewed journal.Trial registration numberISRCTN10378861.

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Routine intraoperative cholangiography during laparoscopic cholecystectomy: application of the 2016 WSES guidelines for predicting choledocholithiasis

Surgical Endoscopy ◽

10.1007/s00464-021-08305-4 ◽

2021 ◽

Author(s):

Hui-Ying Lai ◽

Kuei-Yen Tsai ◽

Hsin-An Chen

Keyword(s):

Laparoscopic Cholecystectomy ◽

Bile Duct ◽

Common Bile Duct ◽

Risk Groups ◽

Intraoperative Cholangiography ◽

Uneventful Recovery ◽

Gallstone Pancreatitis ◽

Cbd Stones ◽

Study Results ◽

Wses Guidelines

Abstract Background Routine use of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) for detecting common bile duct stones remains controversial. The 2016 World Society of Emergency Surgery (WSES) guidelines on acute calculous cholecystitis proposed a risk stratification for choledocholithiasis. Our present study aimed to (1) examine the findings of common bile duct (CBD) stones in patients underwent LC with routine use of IOC, and (2) validate the 2016 WSES risk classes for predicting choledocholithiasis. Methods All patients had LC with IOC routinely performed from November 2012 to December 2017 were reviewed retrospectively. Patients were classified into high-, intermediate-, and low-risk groups based on the 2016 WSES risk classes with modification. Results A total of 990 patients with LC and routine IOC were enrolled. CBD stones were detected in 197 (19.9%) patients. The rate of CBD stone detected in low-, intermediate-, high-risk groups were 0%, 14.2%, and 89.6%, respectively. Predictors as following: evidence of CBD stones on abdominal ultrasound or computed tomography, CBD diameter > 6 mm, total bilirubin > 4 mg/dL, bilirubin level = 1.8–4 mg/dL, abnormal liver biochemical test result other than bilirubin, presence of clinical gallstone pancreatitis had statistical significance between patients with and without CBD stones. Major bile duct injury was found in 4 patients (0.4%). All 4 patients had uneventful recovery after repair surgery. Conclusions Based on our study results, the 2016 WSES risk classes for choledocholithiasis could be an effective approach for predicting the risk of choledocholithiasis. Considering its advantages for detecting CBD stones and biliary injuries, the routine use of IOC is still suggested.

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P-O09 Development of a non face-to-face pre-operative assessment pathway for laparoscopic cholecystectomy

British Journal of Surgery ◽

10.1093/bjs/znab430.119 ◽

2021 ◽

Vol 108 (Supplement_9) ◽

Author(s):

Martin Michel ◽

Ala Saab ◽

Madara Kronberga ◽

Clare Bonner ◽

Helen Fifer ◽

...

Keyword(s):

Laparoscopic Cholecystectomy ◽

Waiting Times ◽

Biliary Disease ◽

Duration Of Symptoms ◽

Face To Face ◽

Blood Tests ◽

Cbd Stones ◽

Initial Surgery ◽

Initial Appointment ◽

Independent Sector

Abstract Background The Covid-19 pandemic has led to markedly reduced capacity in almost all areas of normal face-to-face activity in our hospitals. Prior to the pandemic, the standard pre-operative pathway for all patients included an initial appointment in the outpatients clinic and formal examination before recommending surgery. With the reality of limited clinic capacity, our unit developed a non face-to-face assessment pathway alongside a parallel green operating area in our local Independent Sector (IS) hospitals for laparoscopic cholecystectomy. This study describes and methodology and outcomes of this approach Methods A non face-to-face (telephone) proforma for all new referrals for consideration of laparoscopic cholecystectomy was prepared in April 2020 with the first operations carried out in June 2020. All consultations were carried out by consultant surgeons and included thorough history, careful documentation of previous surgery and duration of symptoms and, where appropriate, patients were told to send images of their abdominal wall if they were unable to describe their scars. The first stage of the consent process was completed at initial appointment and all patients were sent written information about surgery. Patients who had BMI<40, uncomplicated biliary disease (biliary colic, mild cholecystitis, ERCP for CBD stones) and ASA of 1/2 were deemed suitable for surgery in the IS and sent across accordingly. A telephone pre-assessment was completed by the hospital and patients were sent blood tests forms in the post, as well as a Covid test to be completed at home followed by a period of self isolation before surgery. All patients were examined on the day of surgery by the operating surgeon and formal consent taken on the day. Primary outcomes that were recorded were cancellation on the day, transfer to the NHS hospital after surgery and complications. Results From June 2020 to December 2020, when the contract with the IS changed, 218 patients attended the IS hospitals for planned elective laparoscopic cholecystectomy. Four patients (2%) did not have surgery (one cancelled as inappropriate for the Independent Sector, two patients whose Covid swab result was not complete and one patient who no longer wished to have surgery). Three patients required transfer to the NHS hospital for post-operative care (drains inserted after unanticipated difficult surgery). All patients were given details of the surgical SDEC unit at the NHS hospital to allow ease of admission in the event of any problems or complications. 28 patients (13%) attended SDEC within 30 days after surgery; most had blood tests and clinical assessment alone. One patient (<1%) required re-laparoscopy for abdominal pain three days after their initial surgery (washout alone) and 5 patients developed umbilical wound infections after surgery (antibiotics alone). Two patients were found to have CBD stones on MRCP. The waiting time from initial assessment to surgery for patients on this pathway was less than 18 weeks for 168 patients though patients who were not suitable for the Independent Sector have had waiting times that are considerably longer. Conclusions These results demonstrate that it is possible to plan surgery for laparoscopic cholecystectomy without a face-to-face appointment at all which has considerable implications for resource allocation in the future; indeed, this approach has been continued within our unit even as clinic capacity has increased and been rolled out to patients with inguinal or para-umbilical hernia. Use of a green site away from the acute NHS hospital allowed elective surgery for non-urgent pathology to continue with acceptable waiting times even during the worst of the Covid-19 pandemic though patients who were not suitable have had markedly worse experiences and waiting times.

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Migration of Surgical Clips into the Common Bile Duct after Laparoscopic Cholecystectomy

Case Reports in Gastroenterology ◽

10.1159/000453658 ◽

2017 ◽

Vol 10 (3) ◽

pp. 787-792 ◽

Cited By ~ 6

Author(s):

Krishn Kant Rawal

Keyword(s):

Laparoscopic Cholecystectomy ◽

Bile Duct ◽

Common Bile Duct ◽

Endoscopic Retrograde Cholangiopancreatography ◽

Acute Cholangitis ◽

Endoscopic Retrograde ◽

Surgical Clips ◽

Cbd Stones ◽

The Common ◽

Retained Stones

Laparoscopic cholecystectomy (LC) is currently the treatment of choice for symptomatic gallstones. Associated complications include bile duct injury, retained common bile duct (CBD) stones, and migration of surgical clips. Clip migration into the CBD can present with recurrent cholangitis over a period of time. Retained CBD stones can be another cause of recurrent cholangitis. A case of two surgical clips migrating into the common bile duct with few retained stones following LC is reported here. The patient had repeated episodes of fever, pain at epigastrium, jaundice, and pruritus 3 months after LC. Liver function tests revealed features of obstructive jaundice. Ultrasonography of the abdomen showed dilated CBD with few stones. In view of acute cholangitis, an urgent endoscopic retrograde cholangiopancreatography was done, which demonstrated few filling defects and 2 linear metallic densities in the CBD. A few retained stones along with 2 surgical clips were removed successfully from the CBD by endoscopic retrograde cholangiopancreatography after papillotomy using a Dormia basket. The patient improved dramatically following the procedure.

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