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.
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