BackgroundLaparoscopic common bile duct exploration (LCBDE) has emerged as a recommended alternative to endoscopic retrograde cholangiopancreatography (ERCP) for the management of choledocholithiasis. However, its use in the elderly has been limited, and evidence of its safety and efficacy in these patients is yet to be established. This study describes our experience of LCBDE in elderly patients, analysing the safety and efficacy of this technique in comparison to younger patients.MethodsAll patients undergoing laparoscopic cholecystectomy (LC) with LCBDE for choledocholithiasis in our unit between January 2015 and January 2017 were included. Data pertaining to patient demographics, comorbidities, investigations, operative technique and outcomes were analysed. Patients were divided into 2 groups based on age (Group A:<65 years vs Group B: >/ = 65 years) for comparative analysis.Results124 patients (Group A: 65, Group B: 59) were included. Group B were more co-morbid and had a higher ASA grade than Group A. However, there was no significant difference between groups in rates of conversion to open or complications, including bile leak (3.1% vs 5.1%, p = 0.67), retained stone (4.6% vs 1.7%, p = 0.62), or complications according to Clavien-Dindo classification (p = 0.78). Re-intervention rates were also similar between groups (7.7% vs 3.4%, p = 0.44 and 3.1% vs 3.4%, p = 1.0 respectively), as was length of stay.ConclusionDespite higher frequency of comorbidities and ASA grade, LCBDE in elderly patients is safe and effective, and has similar outcomes to younger patients. Therefore elderly patients with choledocholithiasis should be offered LCBDE as an alternative to ERCP.
BackgroundLaparoscopic common bile duct exploration (LCBDE) is gaining popularity over endoscopic retrograde cholangiopancreatography (ERCP) for the management of common bile duct stones. However, its application has been almost exclusively following preoperative stone confirmation via magnetic retrograde cholangiopancreatography (MRCP), endoscopic ultrasound (EUS) or ERCP. We present our series of LCBDE following detection of common bile duct stones with intraoperative imaging (IOI) alone, in consecutive elective and emergency patients with suspected choledocholithiasis.Materials and methodsAll patients with suspected but unconfirmed choledocholithiasis undergoing LC with intention to proceed to LCBDE between January 2015 and June 2017 were included. LCBDE was performed following the discovery of choledocholithiasis on IOI.Results371 patients with suspected choledocholithiasis underwent LC with IOI. CBD stones or obstructing sludge was identified in 107 patients (29%), with sensitivity of 96.2% and specificity of 98.5%. 100 patients, median age 59, went on to have LCBDE as indicated by intraoperative imaging. 76% were performed as emergency cases and conversion to open rate was 2%. There were no mortalities. Bile leak and retained stones occurred in 4% and 3% respectively. 7/100 patients required re-intervention, with re-look laparoscopy (n = 4) and ERCP (n = 3). Median length of stay was 1.5 and 3 days for elective and emergency cases respectively, and 30 readmission rate was 8%.Discussion and conclusionTraditionally patients presenting with suspicion of choledocholithiasis undergo preoperative MRCP/EUS and/or ERCP prior to eventual LC. We propose an alternative, more streamlined, pathway of treatment without requiring preoperative cholangiography, applicable to both elective and emergency patients.
Bile duct stones (BDS) can be managed either prior to laparoscopic cholecystectomy (LC) using endoscopic retrograde cholangiopancreatography (ERCP) or with laparoscopic bile duct exploration (LBDE) at the time of LC. The latter is underutilised. The aim of this study was to use the dataset of the previously performed CholeS study to investigate LBDE hospital volumes, LBDE-to-LC rates, and LBDE outcomes. Methods: Data from 166 United Kingdom/Republic of Ireland hospitals were used to study the utilisation of LBDE in LC patients. Results: Of 8,820 LCs performed, 932 patients (10.6%) underwent preoperative ERCP and 256 patients (2.9%) underwent LBDE. Of the 256 patients who underwent LBDE, 73 patients (28.5%) had undergone prior ERCP and 112 patients (43.8%) had undergone prior magnetic resonance cholangiopancreatography. Fifteen (9.0%) of the 166 included hospitals performed less than five LBDEs in the two-month study period. LBDEs were mainly performed by upper gastrointestinal surgeons (84.4%) and colorectal surgeons (10.0%). Eighty-seven percent of the LBDEs were performed by consultants and 13.0% were performed by trainees. The laparoscopic-to-open conversion rate was 12.5%. The median operation time was 111 minutes (range: 75-155 minutes). Median hospital stay was 6 days (range: 4-11 days) for emergency LBDEs and 1 day (range: 1-4 days) for elective LBDEs. Overall morbidity was 21.5%. Bile leak rate was 5.3%. Thirty-day readmission and mortality rates were 12.1% and 0.4%, respectively. Conclusions: The single-stage approach to managing BDS was underutilised. An additional prospective study with a longer study period is needed to verify this finding.
Background Gallbladder polyps are elevations in the gallbladder wall which project into the lumen. These can be either true polyps or “pseudopolyps” (such as cholesterol or inflammatory deposits or focal adenomyomatosis). Polyp prevalence has been estimated as high as 9.5% in some studies, of which 70% may be pseudopolyps. A small minority of true polyps may display malignant potential. Gallbladder malignancy is aggressive, especially when diagnosed at later stages of disease with poor treatment options and survival outcomes. However, Stage I disease has excellent 5 year survival rates, nearing 100%. Early identification of patients at risk of gallbladder malignancy is highly important and may detect curable disease. Joint guidelines between the European Society of Gastrointestinal and Abdominal Radiology (ESGAR), European Association for Endoscopic Surgery (EAES), International Society of Digestive Surgery – European Federation (EFISDS) and European Society of Gastrointestinal Endoscopy (ESGE) have outlined best practice in regards to management of gallbladder polyps. This audit compared the current practice in a NHS healthcare trust against these guidelines in order to develop trust-wide consensus and guidelines for future management. Methods A PACS based radiology search was conducted, identifying all patients who underwent an ultrasound between 10th December 2020 and 10th December 2021, whose imaging report used the term “gallbladder polyp(s)” within a hospital trust. Patients without a diagnosis of gallbladder polyp were excluded from the audit. Historical patient records were accessed via the trust-based online patient database (Clinical Portal). Data were collected and analysed using Microsoft excel. Patient management was compared against the following ESGAR/EAES/EFISDS/ESGE guidelines: Results A total of fifty six patients fit the inclusion criteria, with an age range of 8 to 96 years. The majority were female (63%). Polyp size ranged from <2mm to 14mm. Patients were predominantly managed by Upper GI surgery, gastroenterology and general practice with the Radiology department performing and reporting ultrasounds and advising management or follow up. Results showed that 86% of patients were appropriately offered surgery for polyps ≥ 10mm. However, 40% of patients with polyps >5mm with risk factors, were not offered cholecystectomy and 44% of those without risk factors were not offered appropriate follow up. The majority of patients with polyps ≤ 5mm with risk factors were not offered ultrasound surveillance. All patients without risk factors with polyps ≤ 5mm were appropriately managed. Conclusions Key findings suggest discrepancies in the management of patients with gallbladder polyps in a NHS Trust. In particular, patients with risk factors and polyps between 6–9mm were not always identified as requiring operative management. Likewise, over half of those without risk factors were not offered surveillance imaging. Poor management and lack of follow up may put patients at risk. The results of this audit demonstrate the need for unified local or national guidelines concerning management of gallbladder polyps and consensus across multiple disciplines.
Background Cholelithiasis is a common problem in the UK affecting approximately 15% of the population. The incidence of synchronous choledocholithiasis is approximately 10-18%. The approach to bile duct stones is variable. Single stage bile duct exploration and cholecystectomy (LC) vs two stage ERCP followed by LC has been shown to be equally safe and as effective with reduced length of stay and number of procedures. We describe the results of a single, high volume centre performing laparoscopic common bile duct exploration (LCBDE) as an alternative to ERCP. Methods All patients undergoing LCBDE at our institution from November 2013 – July 2021 were included in the study. Data were collected from a prospectively maintained institutional database and data points corroborated by electronic patient data on hospital systems. Results 304 patients underwent LCBDE. Median age was 68 (range 21-94). Most cases were performed as urgent/emergency (n = 204, 67% vs n = 100, 33% elective). Bile duct stones were diagnosed pre-operatively in 32.8% cases (n = 100). Intra-operative diagnosis was made using laparoscopic ultrasound (n = 221, 73%), cholangiogram (n = 44, 15%) or combination of both (n = 31, 10%). Laparoscopic completion rate was 92%. Successful stone clearance rate was 98%. 56% were via choledochotomy and 44% trans-cystic. Incidence of bile leak was 4.9% (n = 15). Median length of stay was 2 days post-operatively (range 0–62). The rate of all complications was 13.2%. The rate of mortality was 0.66%. Conclusions This is the largest single case series of LCBDE published. This study has demonstrated that a safe and effective LCBDE service can be delivered within the NHS, with outcome data comparable to defined performance standards. With the evolution of specialist training, intra-operative imaging +/- LCBDE is likely to be the preferred modality of treatment.
Background Acute pancreatitis (AP) is a common surgical presentation with a wide spectrum of severity and outcome. The most common cause of AP is gallstones, accounting for approximately 50% of cases, followed by alcohol excess. Reliable identification of gallstones is crucial as patients can be offered cholecystectomy to prevent recurrence. Current UK guidelines recommend a minimum of two negative ultrasounds to rule out gallstones. The aim of this study was to assess the pickup rate of gallstones on ultrasound for patients admitted with AP and audit our compliance with UK guidelines. Methods All patients admitted with acute pancreatitis between the start of January 2019 to the end of December 2020 were retrospectively analysed. All patients with a known pre-existing cause for pancreatitis such as alcohol excess, chronic pancreatitis, CBD stricture and pancreatic mass were excluded. Electronic records were examined to identify subsequent imaging investigations and final diagnosis. Particular interest was given to whether gallstones were identified, and adherence to UK guidelines. Results 206 patients were identified following the exclusion criteria. 189 underwent an ultrasound on admission, 111 were positive for gallstones. Of the negative ultrasounds (78), 15 underwent a further USS (4 positive), 29 underwent an MRCP (12 positive), 15 had a CT (3 positive) and 3 had an ERCP (3 positive). This left 16 with an unknown aetiology after 1 ultrasound and did not undergo further imaging and therefore did not comply with the current guidelines. Of the 11 patients who had 2 negative ultrasounds 5 had further imaging and all were negative for gallstones. Conclusions In conclusion Gallstone pancreatitis is a common acute surgical presentation of which morbidity and mortality can be significant. Following our retrospective assessment, we deem secondary imaging in the form of USS or MRCP to be necessary in the investigation of acute pancreatitis due to the high pickup rate. Compliance with current guidelines aids diagnostics and ensures appropriate and timely management of this condition leading to improved patient care.
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