Common bile duct stones: analysis of the videolaparoscopic surgical treatment

Abstract

-Context -About 9% of the Brazilian population has gallstones and the incidence increases significantly with aging. The choledocholithiasis is found around 15% of these patients, and a third to half of these cases presented as asymptomatic. Once the lithiasis in the common bile duct is characterized through intraoperative cholangiography, the laparoscopic surgical exploration can be done through the transcystic way or directly through choledochotomy. Objective -To evaluate the results and outcomes of the laparoscopic treatment of common bile duct lithiasis. Methods -Seventy consecutive patients were evaluated. They prospectively underwent the treatment of the lithiasis in the common bile duct and the exploration ways were compared according to the following parameters: criteria on their indication, success in the clearance, surgical complications. It was verified that about ½ of the choledocholithiasis carriers did not show any expression of predictive factors (clinical antecedents of jaundice and/or acute pancreatitis, compatible sonographic data and the pertaining lab tests). The laparoscopic exploration through the transcystic way is favored when there are no criteria for the practice of primary choledochotomy, which are: lithiasis in the proximal bile duct, large (over 8 mm) or numerous calculi (multiple calculosis). Results -The transcystic way was employed in about 50% of the casuistic and the choledochotomy in about 30%. A high success rate (around 80%) was achieved in the clearance of the common bile duct stones through laparoscopic exploration. The transcystic way, performed without fluoroscopy or choledochoscopy, attained a low rate of success (around 45%), being 10% of those by transpapilar pushing of calculi less than 3 mm. The exploration through choledochotomy, either primary or secondary, if the latter was performed after the transcystic route failure, showed high success rate (around 95%). When the indication to choledochotomy was primary, the necessity for choledochoscopy through choledochotomy to help in the removal of the calculi was 55%. However, when choledochotomy was performed secondarily, in situations where the common bile duct diameter was larger than 6 mm, the use of choledochoscopy with the same purpose involved about 20% of the cases. There was no mortality in this series. Conclusion -The laparoscopic exploration of the common bile duct was related to a low rate of morbidity. Therefore, the use of laparoscopy for the treatment of the lithiasis in the common bile duct depends on the criteria for the choice of the best access, making it a safe procedure with very good results. HEADINGS -Choledocholithiasis. Laparoscopy. Cholangiography.

Meta‐analysis of laparoscopic transcysticversustranscholedochal common bile duct exploration for choledocholithiasis

“…None of the 25 studies reported mean BMI. Only one study 20 reported the preoperative laboratory investigation (median (range) bilirubin concentration for LTCE 20 (6-74) μmol/l and Reference Gigot et al 31 Millat et al 34 Arvidsson et al 20 Martin et al 33 Lauter and Froines 24 Tokumura et al 40 Waage et al 42 Jameel et al 22 Zhang et al 19 Hongjun et al 18 Aawsaj et al 28 Overall Heterogeneity: 31 Arvidsson et al 20 Martin et al 33 Lauter and Froines 24 Tokumura et al 40 Waage et al 42 Zhang et al 19 Overall Phillips et al 36 Millat et al 34 Berthou et al 29 Michel et al 25 Topal et al 41 Tan et al 39 Santo et al 38 Mohamed et al 35 Rhodes et al 37 Cuschieri et al 30 Phillips et al 36 Gigot et al 31 Millat et al 34 Berthou et al 29 Martin et al 33 Tokumura et al 40 Waage et al 42 Jameel et al 22 Tai et al 23 Tan et al 39 Zhang et al 19 Aawsaj et al 28 Overall Hongjun et al 18 Berthou et al 29 Martin et al 33 Overall Hongjun et al 18 Reference...…”

“…The median quality score for the RCTs was judged based on the Cochrane Handbook 13 . The quality assessment stratifies the current evidence and projects the need for further research on the topic based on the quality of the available evidence into: high-quality evidence where further research is not expected to change the current confidence in the estimate of the effect size, moderate-quality evidence if further research is likely to influence confidence in the estimated effect and may change it; low-quality evidence if further research is very likely to influence confidence in the estimate of Reference Design n-RCT Phillips et al 36 Gigot et al 31 Millat et al 34 Arvidsson et al 20 Berthou et al 29 DePaula et al 27 Martin et al 33 Lauter and Froines 24 Michel et al 25 Tokumura et al 40 Waage et al 42 Topal et al 41 Jameel et al 22 Tan et al 39 Santo et al 38 Dimov et al 26 Darrien et al 21 Mohamed et al 35 Zhang et al 19 Aawsaj et al 28 Rhodes et al 37 Cuschieri et al 30 Grubnik et al 32 Overall n-RCT heterogeneity: I 2 = 68%, P < 0·05 RCT heterogeneity: I 2 = 72% P < 0·05 Heterogeneity: 2 Forest plot for successful duct clearance in patients with choledocholithiasis undergoing a laparoscopic transcystic or transcholedochal approach. Studies that had 100 per cent success in both arms 18,23 were not included in the analysis, so calculation of an odds ratio was not possible in the pooled analysis.…”

A potential complication following endoscopic retrograde cholangiopancreatography: Subcapsular hepatic hematoma

“…Endoscopic Retrograde Cholangiopancreatography (ERCP), which was introduced into the field of gastroenterology, hepatology and hepato-pancreatico-biliary surgery, has progressed to be an important and essential diagnostic and therapeutic tool for biliary and pancreatic diseases but haemorrhagic complications usually occurs when utilizing Endoscopic Sphincterotomy (EST) or Endoscopic Papillotomy (EPT) [1][2][3][4]. The complication of subcapsular hepatic hematoma after conducting ERCP is uncommon and a likely life-threatening situation in which few cases was reported in the world [5].…”

Порівняльна Оцінка Динаміки Холестатичних Та Цитолітичних Показників І Темпу Декомпресії Жовчних Проток Після Одноетапних Лапароскопічних Та Відкритих Операційних Втручань У Хворих На Холедохолітіаз, Ускладнений Обтураційною Жовтяницею (Повідомлення 2)

“…З розвитком ендовідеохірургічної апаратури та інструментарію, накопиченням досвіду і вдо-сконаленням хірургічної техніки все ширше за-стосовується одноетапна тактика лікування, що включає втручання на жовчній протоці, літоек-стракцію і холецистектомію лапароскопічним способом [10, 11, 12,13,14,15, 16].…”