|
1
|
Raab S, Jagoditsch A, Kurz F, Pimingstorfer P, Schimetta W, Schöfl R, Schrenk P, Schwinghammer C, Ziachehabi A, Shamiyeh A. Comparison of intraoperative versus preoperative ERCP with laparoscopic cholecystectomy for cholecystocholedocholithiasis: a 3-year study at Kepler University Hospital. Surg Endosc 2025; 39:1036-1042. [PMID: 39681682 PMCID: PMC11794371 DOI: 10.1007/s00464-024-11438-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 10/02/2024] [Indexed: 12/18/2024]
Abstract
BACKGROUND Preoperative ERCP followed by cholecystectomy is a common treatment for cholecystocholedocholithiasis. However, intraoperative ERCP has been used more frequently over the last two decades, with few studies assessing various aspects of both methods. We evaluated and compared the management and outcomes of intraoperative ERCP and preoperative ERCP. METHODS This is a retrospective cohort study of a prospective registry. A total of 169 patients with cholecystocholedocholithiasis underwent either intraoperative ERCP or preoperative ERCP followed by cholecystectomy. Between January 2020 and June 2023 patients were further analysed for morbidity, surgical technique, ERCP and surgical indications, length of stay and success rate of ERCP. RESULTS 103 patients (60.9%) underwent intraoperative ERCP and 66 patients (39.1%) an ERCP later followed by cholecystectomy. Patients with intraoperative ERCP tended to have a lower rate of post-ERCP pancreatitis (3.9% vs. 6.1%; P = 0.537), fewer ERCP complications (3.9% vs. 10.6%; P = 0.116), a reduced hospital stay (8 vs. 13.8 days; P < 0.001) and a lower cannulation failure rate of the common bile duct during ERCP (1.9% vs. 6.1%; P = 0.088). CONCLUSIONS Our study identified several advantages of intraoperative simultaneous ERCP over upfront ERCP, suggesting that intraoperative ERCP may be a viable and safe option for the comprehensive management of cholecystocholedocholithiasis.
Collapse
Affiliation(s)
- Sandra Raab
- Department for General-, and Visceral Surgery, Kepler University Hospital, Krankenhausstraße 9, Linz, Austria.
- Medical Faculty, Johannes Kepler University, Linz, Austria.
| | - Alexander Jagoditsch
- Department for General-, and Visceral Surgery, Kepler University Hospital, Krankenhausstraße 9, Linz, Austria
- Medical Faculty, Johannes Kepler University, Linz, Austria
| | - Franz Kurz
- Department for General-, and Visceral Surgery, Kepler University Hospital, Krankenhausstraße 9, Linz, Austria
- Medical Faculty, Johannes Kepler University, Linz, Austria
| | - Philipp Pimingstorfer
- Medical Faculty, Johannes Kepler University, Linz, Austria
- Department of Internal Medicine and Gastroenterology, Kepler University Hospital, Linz, Austria
| | - Wolfgang Schimetta
- Department of Applied Systems Research & Statistics, Johannes Kepler University, Linz, Austria
| | - Rainer Schöfl
- Department of Gastroenterology, Hepatology, Endocrinology, Ordensklinikum, Linz, Austria
| | - Peter Schrenk
- Department for General-, and Visceral Surgery, Kepler University Hospital, Krankenhausstraße 9, Linz, Austria
- Medical Faculty, Johannes Kepler University, Linz, Austria
| | | | - Alexander Ziachehabi
- Department of Gastroenterology, Hepatology, Endocrinology, Ordensklinikum, Linz, Austria
| | - Andreas Shamiyeh
- Department for General-, and Visceral Surgery, Kepler University Hospital, Krankenhausstraße 9, Linz, Austria
- Medical Faculty, Johannes Kepler University, Linz, Austria
| |
Collapse
|
|
2
|
Nie S, Fu S, Fang K. Comparison of one-stage treatment versus two-stage treatment for the management of patients with common bile duct stones: A meta-analysis. Front Surg 2023; 10:1124955. [PMID: 36816010 PMCID: PMC9935819 DOI: 10.3389/fsurg.2023.1124955] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 01/11/2023] [Indexed: 02/05/2023] Open
Abstract
Background Cholelithiasis is a frequently occurring disease in clinic. Due to changes in people's living environments, dietary habits and the aging population, cholelithiasis incidence is increasing. Currently, laparoscopic cholecystectomy (LC) is the preferred treatment for gallbladder stones, but the surgical method for patients with choledocholithiasis is controversial. An endoscopic retrograde cholangiopancreatography (pERCP) is performed preoperatively, followed by LC as the general treatment method. However, pERCP still has some disadvantages, such as prolonged hospital stay, increased incidence of postoperative pancreatitis, and increased duration of anesthesia. Therefore, intraoperative endoscopic retrograde cholangiopancreatography (iERCP) is proposed. Objective To compare the efficacy and safety of one-stage treatment and two-stage treatment for the management of patients with cholecystolithiasis and choledocholithiasis. Search strategy PubMed, Embase, Web of Science, and Cochrane databases were searched through October 2022. The search terms include cholangiolithiasis/bile duct stones/calculi, endoscopic retrograde cholangiopancreatography/ERCP, endoscopic sphincterotomy/EST, laparoendoscopic rendezvous (LERV), and laparoscopic cholecystectomy/LC. Selection criteria For the treatment of patients with cholecystolithiasis and choledocholithiasis in adults, randomized controlled trials (RCTs) comparing LC with iERCP vs. pERCP followed by LC were conducted. Data collection and analysis Data extraction and quality assessment were performed by two reviewers. We used Revman version 5.3 to analyze the collected data. The trials were grouped according to the evaluation results such as the overall mortality rate, overall morbidity rate, clearance rate of choledocholithiasis, incidence of pancreatitis, the length of hospitalization, and the length of operation. Results 9 RCTs (950 participants) were included in this meta-analyses. The overall morbidity rate in LC + iERCP group is lower than that in LC + pERCP group (RR: 0.57, 95% CI = 0.41-0.79, p = 0.0008). The clearance rate of choledocholithiasis in LC + iERCP group was almost the same as that in LC + pERCP group (RR: 1.03, 95% CI = 0.98-1.08, p = 0.28). The incidence of pancreatitis in LC + iERCP group is lower than that in LC + pERCP group (RR: 0.29, 95% CI = 0.13-0.67, p = 0.004). The length of operation of the LC + iERCP group seems to be similar to that of the LC + pERCP group (MD: 16.63 95% CI = -5.98-39.24, p = 0.15). LC + iERCP group has a shorter length of hospitalization than that in LC + pERCP group (MD: -2.68 95% CI = -3.39--1.96, p < 0.00001). LC + iERCP group has lower postoperative second ERCP rate than that in LC + pERCP group (RR: 0.13, 95% CI = 0.03-0.57, p = 0.006). Conclusion Our study suggest that LC + iERCP may be a better option than LC + pERCP in the management of patients with both cholecystolithiasis and choledocholithiasis. This procedure can reduce the overall incidence of postoperative complications, especially the occurrence of postoperative pancreatitis. It could shorten the length of hospital stay, reduce postoperative second ERCP rate.
Collapse
Affiliation(s)
- Shanmao Nie
- Department of Hepatobiliary Surgery, Luzhou people's Hospital, Luzhou, China
| | - Shangyu Fu
- Department of Anesthesiology, Luzhou people's Hospital, Luzhou, China
| | - Kaiyan Fang
- Department of Anesthesiology, Luzhou people's Hospital, Luzhou, China,Correspondence: Kaiyan Fang
| |
Collapse
|
|
3
|
Lagouvardou E, Martines G, Tomasicchio G, Laforgia R, Pezzolla A, Caputi Iambrenghi O. Laparo-endoscopic management of chole-choledocholithiasis: Rendezvous or intraoperative ERCP? A single tertiary care center experience. Front Surg 2022; 9:938962. [PMID: 36117813 PMCID: PMC9470774 DOI: 10.3389/fsurg.2022.938962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction The management of chole-choledocholithiasis remains a matter of debate to preserve minimal invasive management and different options have been proposed, with single- or two-stage approaches. Two techniques of single-stage approach are intraoperative ERCP and laparoscopic rendezvous, which have the great advantage of reducing the length of hospital stay with increased patient compliance. This retrospective study aims to evaluate and compare the efficacy and safety of intraoperative ERCP and rendezvous technique for more than 15 years. Materials and methods Clinical records of 113 patients who underwent single-stage management for chole-choledocholithiasis between January 2003 and December 2020 were retrospectively reviewed using a prospectively maintained database. Patients were separated into two groups: those managed with intraoperative ERCP and those with rendezvous, and their intraoperative and postoperative parameters were compared. All patients were followed up for 6 months in an outpatient setting. Results A total of 68 (60%) patients were treated with intraoperative ERCP, while the remaining 45 (40%) were treated with rendezvous. There were no significant differences in terms of comorbidities. ERCP was performed with a median operative time of 145 min (104–168) and an endoscopic time of 27 min (15–36). Meanwhile, rendezvous was performed with a significantly lower operative [120 min (94–147)] and endoscopic time [15 min (12–22)]. No intraoperative complications were recorded. Patients treated with rendezvous had a significantly shorter median hospitality stay [4 (3–5) vs. 3 (2–4) days, p < 0.05]. No hospital readmissions or mortalities were observed in either group after 30 days. Ten mild pancreatitis cases were observed, mainly in the intraoperative ERCP group (9 vs. 1, p < 0.05), and all were treated conservatively. Only two patients treated with intraoperative ERCP developed biliary complications later on. Conclusion Laparoscopic rendezvous should be considered a preferable alternative to intraoperative ERCP for the treatment of patients with concomitant CBD stones and gallstones.
Collapse
Affiliation(s)
| | - Gennaro Martines
- Department of Emergency and Organ Transplantation, School of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Giovanni Tomasicchio
- Department of Emergency and Organ Transplantation, School of Medicine, University of Bari Aldo Moro, Bari, Italy
- Correspondence: Giovanni Tomasicchio
| | - Rita Laforgia
- Azienda Ospedaliero Universitaria Consorziale Policlinico di Bari, Bari, Italy
| | - Angela Pezzolla
- Department of Emergency and Organ Transplantation, School of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Onofrio Caputi Iambrenghi
- Department of Emergency and Organ Transplantation, School of Medicine, University of Bari Aldo Moro, Bari, Italy
| |
Collapse
|
|
4
|
Vaccari S, Minghetti M, Lauro A, Bellini MI, Ussia A, Khouzam S, Marino IR, Cervellera M, D'Andrea V, Tonini V. Destiny for Rendezvous: Is Cholecysto/Choledocholithiasis Better Treated with Dual- or Single-Step Procedures? Dig Dis Sci 2022; 67:1116-1127. [PMID: 35318553 DOI: 10.1007/s10620-022-07450-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 02/05/2023]
Abstract
Biliary lithiasis is common worldwide, affecting almost 20% of the general population, though few experience symptoms. The frequency of choledocholithiasis in patients with symptomatic cholelithiasis is estimated to be 10-33%, depending on patients' age. Unlike gallbladder lithiasis, the medical and surgical treatment of common bile duct stones is uncertain, having changed over the last few years. The prior gold standard treatment for cholelithiasis and choledocholithiasis was open cholecystectomy with bile duct clearance, choledochotomy, and/or surgical sphincterotomy. In the last 10-15 years, new treatment approaches to the complex pathology of choledocholithiasis have emerged with the advent of endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic surgery, and advanced diagnostic procedures. Although ERCP followed by laparoscopic cholecystectomy is the preferred mode of management, a single-step strategy (laparo-endoscopic rendezvous) has gained acceptance due to lesser morbidity and a lower risk of iatrogenic damage. Given the above, a tailored approach relying on careful evaluation of the disease is necessary in order to minimize complication risks and overall costs. Yet, the debate remains open, with no consensus on the superiority of laparo-endoscopic rendezvous to more conventional approaches.
Collapse
Affiliation(s)
- S Vaccari
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | - M Minghetti
- Emergency Surgery Department, St. Orsola University Hospital, Bologna, Italy
| | - A Lauro
- Department of Surgical Sciences, Sapienza University, Rome, Italy.
| | - M I Bellini
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | - A Ussia
- Emergency Surgery Department, St. Orsola University Hospital, Bologna, Italy
| | - S Khouzam
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - I R Marino
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - M Cervellera
- Department of General Surgery, Ospedale Santissima Annunziata, Taranto, Italy
| | - V D'Andrea
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | - V Tonini
- Emergency Surgery Department, St. Orsola University Hospital, Bologna, Italy
| |
Collapse
|
|
5
|
Zhu J, Li G, Du P, Zhou X, Xiao W, Li Y. Laparoscopic common bile duct exploration versus intraoperative endoscopic retrograde cholangiopancreatography in patients with gallbladder and common bile duct stones: a meta-analysis. Surg Endosc 2021; 35:997-1005. [PMID: 33025251 DOI: 10.1007/s00464-020-08052-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 09/26/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND To compare the efficacy and safety of laparoscopic common bile duct exploration plus laparoscopic cholecystectomy (LCBDE + LC) with intraoperative endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy (IO-ERCP + LC) for the treatment of gallbladder and common bile duct (CBD) stones. METHODS We searched PubMed, Ovid, and Cochrane Library from their inception dates to April 2020, for studies that compared the efficacy and safety of LCBDE + LC with those of IO-ERCP + LC in patients with gallbladder and CBD stones. The technical success, morbidity, major morbidity, biliary leak, postoperative pancreatitis, conversion, retained stones, operative time, and postoperative hospital stay were compared between these two approaches. RESULTS Five randomized controlled trials involving 860 patients were evaluated. Overall, no significant difference was found between LCBDE + LC and IO-ERCP + LC regarding technical success, morbidity, major morbidity, and the conversion rate. Biliary leak and retained stones were significantly more prevalent in the LCBDE + LC group, while postoperative pancreatitis was significantly more prevalent in the IO-ERCP + LC group. CONCLUSIONS LCBDE + LC and IO-ERCP + LC have similar efficacy and safety in terms of technical success, morbidity, major morbidity, and conversion rate. However, LCBDE + LC is associated with a higher biliary leak rate, lower postoperative pancreatitis rate, and higher rate of retained stones.
Collapse
Affiliation(s)
- Jisheng Zhu
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No.17 Yongwai Zhengjie, Nanchang, 330006, Jiangxi, China
| | - Guoyong Li
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No.17 Yongwai Zhengjie, Nanchang, 330006, Jiangxi, China
| | - Peng Du
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No.17 Yongwai Zhengjie, Nanchang, 330006, Jiangxi, China
| | - Xin Zhou
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No.17 Yongwai Zhengjie, Nanchang, 330006, Jiangxi, China
| | - Weidong Xiao
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No.17 Yongwai Zhengjie, Nanchang, 330006, Jiangxi, China
| | - Yong Li
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No.17 Yongwai Zhengjie, Nanchang, 330006, Jiangxi, China.
| |
Collapse
|
|
6
|
Syrén EL, Sandblom G, Eriksson S, Eklund A, Isaksson B, Enochsson L. Postoperative rendezvous endoscopic retrograde cholangiopancreaticography as an option in the management of choledocholithiasis. Surg Endosc 2020; 34:4883-4889. [PMID: 31768727 PMCID: PMC7572344 DOI: 10.1007/s00464-019-07272-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 11/12/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Rendezvous endoscopic retrograde cholangiopancreaticography (ERCP) is a well-established method for treatment of choledocholithiasis. The primary aim of this study was to determine how different techniques for management of common bile duct stone (CBDS) clearance in patients undergoing cholecystectomy have changed over time at tertiary referral hospitals (TRH) and county/community hospitals (CH). The secondary aim was to see if postoperative rendezvous ERCP is a safe, effective and feasible alternative to intraoperative rendezvous ERCP in the management of CBDS. METHODS Data were retrieved from the Swedish registry for cholecystectomy and ERCP (GallRiks) 2006-2016. All cholecystectomies, where CBDS were found at intraoperative cholangiography, and with complete 30-day follow-up (n = 10,386) were identified. Data concerning intraoperative and postoperative complications, readmission and reoperation within 30 days were retrieved for patients where intraoperative ERCP (n = 2290) and preparation for postoperative ERCP were performed (n = 2283). RESULTS Intraoperative ERCP increased (7.5% 2006; 43.1% 2016) whereas preparation for postoperative ERCP decreased (21.2% 2006; 17.2% 2016) during 2006-2016. CBDS management differed between TRHs and CHs. Complications were higher in the postoperative rendezvous ERCP group: Odds Ratio [OR] 1.69 (95% confidence interval [CI] 1.16-2.45) for intraoperative complications and OR 1.50 (CI 1.29-1.75) for postoperative complications. Intraoperative bleeding OR 2.46 (CI 1.17-5.16), postoperative bile leakage OR 1.89 (CI 1.23-2.90) and postoperative infection with abscess OR 1.55 (CI 1.05-2.29) were higher in the postoperative group. Neither post-ERCP pancreatitis, postoperative bleeding, cholangitis, percutaneous drainage, antibiotic treatment, ICU stay, readmission/reoperation within 30 days nor 30-day mortality differed between groups. CONCLUSIONS Techniques for management of CBDS found at cholecystectomy have changed over time and differ between TRH and CH. Rendezvous ERCP is a safe and effective method. Even though intraoperative rendezvous ERCP is the preferred method, postoperative rendezvous ERCP constitutes an acceptable alternative where ERCP resources are lacking or limited.
Collapse
Affiliation(s)
- Eva-Lena Syrén
- Department of Surgical Sciences, Uppsala University, 751 35, Uppsala, Sweden.
- Centre of Clinical Research, Västmanland Hospital, Västerås, Sweden.
| | - Gabriel Sandblom
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institute, Stockholm, Sweden
- Department of Surgery, Södersjukhuset, Stockholm, Sweden
| | - Staffan Eriksson
- Department of Surgical Sciences, Uppsala University, 751 35, Uppsala, Sweden
- Centre of Clinical Research, Västmanland Hospital, Västerås, Sweden
| | - Arne Eklund
- Department of Surgical Sciences, Uppsala University, 751 35, Uppsala, Sweden
- Centre of Clinical Research, Västmanland Hospital, Västerås, Sweden
| | - Bengt Isaksson
- Department of Surgical Sciences, Uppsala University, 751 35, Uppsala, Sweden
| | - Lars Enochsson
- Sunderby Research Unit, Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| |
Collapse
|
|
7
|
Syrén EL, Enochsson L, Eriksson S, Eklund A, Isaksson B, Sandblom G. Cardiovascular complications after common bile duct stone extractions. Surg Endosc 2020; 35:3296-3302. [PMID: 32613302 PMCID: PMC8195933 DOI: 10.1007/s00464-020-07766-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 06/25/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Common bile duct stone (CBDS) is a common condition the rate of which increases with age. Decision to treat in particular elderly and frail patients with CBDS is often complex and requires careful assessment of the risk for treatment-related cardiovascular complications. The aim of this study was to compare the rate of postoperative cardiovascular events in CBDS patients treated with the following: ERCP only; cholecystectomy only; cholecystectomy followed by delayed ERCP; cholecystectomy together with ERCP; or ERCP followed by delayed cholecystectomy. METHODS The study was based on data from procedures for gallstone disease registered in the Swedish National Quality Register for Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography (GallRiks) 2006-2014. ERCP and cholecystectomy procedures performed for confirmed or suspected CBDS were included. Postoperative events were registered by cross-matching GallRiks with the National Patient Register (NPR). A postoperative cardiovascular event was defined as an ICD-code in the discharge notes indicating myocardial infarct, pulmonary embolism or cerebrovascular disease within 30 days after surgery. In cases where a patient had undergone ERCP and cholecystectomy on separate occasions, the 30-day interval was timed from the first intervention. RESULTS A total of 23,591 underwent ERCP or cholecystectomy for CBDS during the study period. A postoperative cardiovascular event was registered in 164 patients and death within 30 days in 225 patients. In univariable analysis, adverse cardiovascular event and death within 30 days were more frequent in patients who underwent primary ERCP (p < 0.05). In multivariable analysis, adjusting for history of cardiovascular disease or events, neither risk for cardiovascular complication nor death within 30 days remained statistically significant in the ERCP group. CONCLUSIONS Primary ERCP as well as cholecystectomy may be performed for CBDS with acceptable safety. More studies are required to provide reliable guidelines for the management of CBDS.
Collapse
Affiliation(s)
- Eva-Lena Syrén
- Department of Surgical Sciences, Uppsala University, 751 35, Uppsala, Sweden. .,Centre for Clinical Research, Västmanland Hospital, Västerås, Sweden.
| | - Lars Enochsson
- Department of Surgical and Perioperative Sciences, Sunderby Research Unit, Umeå University, SurgeryUmeå, Sweden
| | - Staffan Eriksson
- Department of Surgical Sciences, Uppsala University, 751 35, Uppsala, Sweden.,Centre for Clinical Research, Västmanland Hospital, Västerås, Sweden
| | - Arne Eklund
- Department of Surgical Sciences, Uppsala University, 751 35, Uppsala, Sweden.,Centre for Clinical Research, Västmanland Hospital, Västerås, Sweden
| | - Bengt Isaksson
- Department of Surgical Sciences, Uppsala University, 751 35, Uppsala, Sweden
| | - Gabriel Sandblom
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institute, Stockholm, Sweden.,Department of Surgery, Södersjukhuset, Stockholm, Sweden
| |
Collapse
|
|
8
|
Laparoendoscopic rendezvous versus ERCP followed by laparoscopic cholecystectomy for the management of cholecysto-choledocholithiasis: a retrospectively cohort study. Surg Endosc 2019; 34:2483-2489. [PMID: 31428853 DOI: 10.1007/s00464-019-07051-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 07/31/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND There are a variety of strategies for the treatment of patients with cholecysto-choledocholithiasis (CCL). Although the surgical approach of choice is preoperative ERCP and laparoscopic cholecystectomy (ERCP + LC), controversy remains regarding which procedure is optimal for CCL. METHODS To evaluate the safety and effectiveness of laparoendoscopic rendezvous (LERV) versus ERCP + LC for CCL, a total of 528 patients with CCL were retrospectively studied from January 2013 to December 2018. The patients were scheduled to undergo either the LERV or ERCP + LC procedure. The LERV group included 123 cases, whereas the ERCP + LC group contained 137 cases. The incidence of postoperative complications, success of stone clearance, length of hospital stay, and hospitalization charges were statistically analyzed. RESULTS The incidence of pancreatitis was lower in the LERV group than in the ERCP + LC group (3/123 vs. 12/137, P = 0.0291). The median level of post-ERCP amylase was much lower in the LERV group (202.5 U/dL vs. 328.1 U/dL, P < 0.01). However, there was no significant difference in the stone clearance rate or other early complications between the two groups. Further study showed that the length of hospital stay and cost in the LERV group were less than those in the ERCP + LC group (12 days vs. 18 days, P < 0.01; 53591.4¥ vs. 60089.2¥, P < 0.01). In addition, more patients in the two-stage procedure group experienced later biliary complications compared with those in the one-stage approach group (34/137 vs. 4/123, P < 0.05). However, the median operation time was 107.7 min in the two-stage group and 139.8 min in the one-stage group (P < 0.05). CONCLUSIONS The LERV technique is a safe and effective approach for CCL with lower pancreatitis; it was associated with few later biliary complications, shortened hospital stays, and fewer charges but significantly longer operative time.
Collapse
|
|
9
|
Bove A, Panaccio P, di Renzo R, Palone G, Ricciardiello M, Ciuffreda S, Bongarzoni G. How to choose the most appropriate technique for the single-stage treatment of cholecysto-choledocolithiasis? Gastroenterol Rep (Oxf) 2019; 7:258-262. [PMID: 31413832 PMCID: PMC6688737 DOI: 10.1093/gastro/goz022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 01/24/2019] [Accepted: 03/01/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND We utilized transcystic clearance and intra-operative papillotomy through a rendezvous technique for the treatment of cholecysto-choledocolithiasis. The goal of this study was to evaluate the reliability of pre-operative parameters to address the most suitable surgical procedure. METHODS A total of 180 patients affected by calculi of the gallbladder and bile duct underwent the single-stage treatment. According to several pre-operative parameters, 141 patients had to supposedly undergo transcystic clearance of the bile duct, while 39 patients had to be treated with the rendezvous technique. All patients were treated with the sequential procedure: first, we tried the transcystic procedure and, if there was a failure, we used a rendezvous technique. We prospectively analysed each group based on a series of variables such as sex, age, operative time, success rate of proposed treatment, conversion rate, post-operative complications and hospital stay. RESULTS Transcystic clearance was successful in 134 out of 141 patients (95.0%), while 2 patients needed to undergo a laparo-endoscopy procedure (failure). Thirty-five out of 39 patients (89.7%) obtained common bile-duct (CBD) clearance through the rendezvous technique, while 1 patient obtained clean-up through the simple transcystic procedure (failure). Five out of 141 patients with transcystic clearance and 3 out of 39 patients with the rendezvous technique underwent laparotomy CBD clearance with conversion rates of 3.5% and 7.7%, respectively. Post-operative complications showed similar percentages for both procedures. However, the surgical time turned out to be longer for the rendezvous technique. CONCLUSIONS The one-stage procedure for the treatment of cholecysto-choledocolithiasis was possible in 94% of the cases utilizing a surgical technique selected according to the patient's case history. The pre-operative parameters, such as jaundice, CBD diameters and stone diameters, have certified their reliability as good predictors of the most suitable procedure to follow.
Collapse
Affiliation(s)
- Aldo Bove
- Department of Medicine, Dentistry and Biotechnology, University ‘G. D’Annunzio’, Via dei Vestini, Chieti, Italy
| | - Paolo Panaccio
- Department of Medicine, Dentistry and Biotechnology, University ‘G. D’Annunzio’, Via dei Vestini, Chieti, Italy
| | - Raffaella di Renzo
- Department of Medicine, Dentistry and Biotechnology, University ‘G. D’Annunzio’, Via dei Vestini, Chieti, Italy
| | - Gino Palone
- Department of Medicine, Dentistry and Biotechnology, University ‘G. D’Annunzio’, Via dei Vestini, Chieti, Italy
| | - Marco Ricciardiello
- Department of Medicine, Dentistry and Biotechnology, University ‘G. D’Annunzio’, Via dei Vestini, Chieti, Italy
| | - Sara Ciuffreda
- Department of Medicine, Dentistry and Biotechnology, University ‘G. D’Annunzio’, Via dei Vestini, Chieti, Italy
| | - Giuseppe Bongarzoni
- Department of Medicine, Dentistry and Biotechnology, University ‘G. D’Annunzio’, Via dei Vestini, Chieti, Italy
| |
Collapse
|
|
10
|
Noel R, Arnelo U, Swahn F. Intraoperative versus postoperative rendezvous endoscopic retrograde cholangiopancreatography to treat common bile duct stones during cholecystectomy. Dig Endosc 2019; 31:69-76. [PMID: 29947437 DOI: 10.1111/den.13222] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 06/22/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM The rendezvous postoperative endoscopic retrograde cholangiopancreatography (ERCP) technique has been introduced as a modification of the single-session rendezvous intraoperative ERCP procedure in the management of concurrent common bile duct stones during cholecystectomy. There are no reports on the impact of this modified technique on post-ERCP morbidity. The objective of the present study was to study and compare the rendezvous techniques in terms of procedure-associated morbidities, such as post-ERCP pancreatitis and postoperative infections. METHODS The Swedish National Registry for Gallstone Disease and ERCP was searched for ERCP procedures cross-matched with cholecystectomies for the same patient carried out for gallstone indications between 2008 and 2014. A total of 1770 rendezvous ERCP procedures were retrieved and included in this study. The ERCP procedures were considered rendezvous intraoperative or rendezvous postoperative, depending on whether the ERCP procedure was carried out during or after completing the cholecystectomy. RESULTS There were 1205 and 565 ERCP procedures in the rendezvous intraoperative and the rendezvous postoperative groups, respectively. The cohorts were similar in age and gender distribution. Overall complication rates were higher in the rendezvous postoperative group compared with the rendezvous intraoperative group (19.7% vs 14%, P = 0.004), involving specifically post-ERCP pancreatitis (6.4% vs 3.2% P = 0.003) and postoperative infections (4.4% vs 2.3% P = 0.028). Despite similar stone clearance rates, there were higher rates of retained stones in the rendezvous postoperative group (5.5% vs 0.6%, P < 0.001). CONCLUSIONS Single-session rendezvous intraoperative ERCP is superior to the rendezvous postoperative ERCP technique in terms of post-ERCP pancreatitis and postoperative infections.
Collapse
Affiliation(s)
- Rozh Noel
- Division of Surgery, CLINTEC, Karolinska Institutet and Centre for Digestive Diseases at Karolinska University Hospital, Stockholm, Sweden
| | - Urban Arnelo
- Division of Surgery, CLINTEC, Karolinska Institutet and Centre for Digestive Diseases at Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Swahn
- Department of Surgery, Skåne University Hospital at Lund, Lund University, Lund, Sweden
| |
Collapse
|
|
11
|
Chang HY, Wang CJ, Liu B, Wang YZ, Wang WJ, Wang W, Li D, Li YL. Ursodeoxycholic acid combined with percutaneous transhepatic balloon dilation for management of gallstones after elimination of common bile duct stones. World J Gastroenterol 2018; 24:4489-4498. [PMID: 30356997 PMCID: PMC6196333 DOI: 10.3748/wjg.v24.i39.4489] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 08/29/2018] [Accepted: 10/05/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the effectiveness and safety of combined ursodeoxycholic acid and percutaneous transhepatic balloon dilation for management of gallstones after expulsion of common bile duct (CBD) stones.
METHODS From April 2014 to May 2016, 15 consecutive patients (6 men and 9 women) aged 45-86 (mean, 69.07 ± 9.91) years suffering from CBD stones associated with gallstones were evaluated. Good gallbladder contraction function was confirmed by type B ultrasonography. Dilation of the CBD and cystic duct was detected. Percutaneous transhepatic balloon dilation of the papilla was performed, ursodeoxycholic acid was administered, and all patients had a high-fat diet. All subjects underwent repeated cholangiography, and percutaneous transhepatic removal was carried out in patients with secondary CBD stones originating from the gallbladder.
RESULTS All patients underwent percutaneous transhepatic balloon dilation with a primary success rate of 100%. The combined therapy was successful in 86.7% of patients with concomitant CBD stones and gallstones. No remaining stones were detected in the gallbladder. Transient adverse events include abdominal pain (n = 1), abdominal distension (n = 1), and fever (n = 1). Complications were treated successfully via nonsurgical management without long-term complications. No procedure-related mortality occurred.
CONCLUSION For patients with concomitant CBD stones and gallstones, after percutaneous transhepatic removal of primary CBD stones, oral ursodeoxycholic acid and a high-fat diet followed by percutaneous transhepatic removal of secondary CBD stones appear to be a feasible and effective option for management of gallstones.
Collapse
Affiliation(s)
- Hai-Yang Chang
- Department of Intervention Medicine, the Second Hospital of Shandong University, Jinan 250033, Shandong Province, China
- Interventional Oncology Institute, Shandong University, Jinan 250033, Shandong Province, China
| | - Chang-Jun Wang
- Department of Radiology, Jiyang People’s Hospital, Jinan 251400, Shandong Province, China
| | - Bin Liu
- Department of Intervention Medicine, the Second Hospital of Shandong University, Jinan 250033, Shandong Province, China
- Interventional Oncology Institute, Shandong University, Jinan 250033, Shandong Province, China
| | - Yong-Zheng Wang
- Department of Intervention Medicine, the Second Hospital of Shandong University, Jinan 250033, Shandong Province, China
- Interventional Oncology Institute, Shandong University, Jinan 250033, Shandong Province, China
| | - Wu-Jie Wang
- Department of Intervention Medicine, the Second Hospital of Shandong University, Jinan 250033, Shandong Province, China
- Interventional Oncology Institute, Shandong University, Jinan 250033, Shandong Province, China
| | - Wei Wang
- Department of Intervention Medicine, the Second Hospital of Shandong University, Jinan 250033, Shandong Province, China
- Interventional Oncology Institute, Shandong University, Jinan 250033, Shandong Province, China
| | - Dong Li
- Department of Intervention Medicine, the Second Hospital of Shandong University, Jinan 250033, Shandong Province, China
- Interventional Oncology Institute, Shandong University, Jinan 250033, Shandong Province, China
| | - Yu-Liang Li
- Department of Intervention Medicine, the Second Hospital of Shandong University, Jinan 250033, Shandong Province, China
- Interventional Oncology Institute, Shandong University, Jinan 250033, Shandong Province, China
| |
Collapse
|
|
12
|
Al-Temimi MH, Trujillo C, Shah M, Rangarajan S, Kim E, Chandrasekaran B, Handman D, Johna S. Same-Day versus Conventional Different-Day Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Cholecystectomy: A Multi-Center Retrospective Study. Am Surg 2018. [DOI: 10.1177/000313481808401029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Same-day endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy (LC) could potentially reduce hospital length of stay (HLOS). Patients undergoing same-day procedures (N = 164) between 2012 and 2014 were compared with different-day procedures performed in the second half of 2014 (N = 276), in the Kaiser Permanente Southern California database. Both groups had comparable baseline characteristics. ERCP success rate (97.5% vs 93.5%), overall postoperative morbidity (3.66% vs 3.99%), and retained stones (2.5% vs 5.8%) were not different between groups ( P > 0.05); however, HLOS was shorter in the same-day group (2.99 ± 2.34 vs 3.84 ± 2.52 days, P < 0.001). Morbidity, procedure success, and HLOS were not different in the same-day group, whether ERCP was performed before or after LC ( P > 0.05). In the same-day group, those undergoing single anesthesia had higher BMI (40.1 ± 10.8 vs 30.3 ± 6.6) and were more likely to have gastric bypass (30% vs 0%) than those undergoing separate anesthesia sessions ( P < 0.01). Longer HLOS (4.8 ± 3.5 vs 2.9 ± 2.2 days) and higher estimated blood loss (65 ± 90 mL vs 20 ± 29 mL) were also associated with the single-anesthetic session ( P < 0.01). ERCP performed on the same day of LC reduces HLOS without increasing morbidity. This approach does not affect postoperative morbidity and ERCP success rate, whether ERCP was performed before or after LC.
Collapse
Affiliation(s)
- Mohammed H. Al-Temimi
- Kaiser Permanente Fontana Medical Center, Fontana, California
- Arrowhead Regional Medical Center, Colton, California
| | - Charles Trujillo
- Kaiser Permanente Fontana Medical Center, Fontana, California
- Arrowhead Regional Medical Center, Colton, California
| | - Mital Shah
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, California
| | - Sriram Rangarajan
- Kaiser Permanente Fontana Medical Center, Fontana, California
- Arrowhead Regional Medical Center, Colton, California
| | - Edwin Kim
- Kaiser Permanente Fontana Medical Center, Fontana, California
- Arrowhead Regional Medical Center, Colton, California
| | - Bindupryia Chandrasekaran
- Kaiser Permanente Fontana Medical Center, Fontana, California
- Arrowhead Regional Medical Center, Colton, California
| | - David Handman
- Kaiser Permanente Fontana Medical Center, Fontana, California
| | - Samir Johna
- Kaiser Permanente Fontana Medical Center, Fontana, California
- Arrowhead Regional Medical Center, Colton, California
| |
Collapse
|
|
13
|
Vettoretto N, Arezzo A, Famiglietti F, Cirocchi R, Moja L, Morino M. Laparoscopic-endoscopic rendezvous versus preoperative endoscopic sphincterotomy in people undergoing laparoscopic cholecystectomy for stones in the gallbladder and bile duct. Cochrane Database Syst Rev 2018; 4:CD010507. [PMID: 29641848 PMCID: PMC6494553 DOI: 10.1002/14651858.cd010507.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The management of gallbladder stones (lithiasis) concomitant with bile duct stones is controversial. The more frequent approach is a two-stage procedure, with endoscopic sphincterotomy and stone removal from the bile duct followed by laparoscopic cholecystectomy. The laparoscopic-endoscopic rendezvous combines the two techniques in a single-stage operation. OBJECTIVES To compare the benefits and harms of endoscopic sphincterotomy and stone removal followed by laparoscopic cholecystectomy (the single-stage rendezvous technique) versus preoperative endoscopic sphincterotomy followed by laparoscopic cholecystectomy (two stages) in people with gallbladder and common bile duct stones. SEARCH METHODS We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, Science Citation Index Expanded Web of Science, and two trials registers (February 2017). SELECTION CRITERIA We included randomised clinical trials that enrolled people with concomitant gallbladder and common bile duct stones, regardless of clinical status or diagnostic work-up, and compared laparoscopic-endoscopic rendezvous versus preoperative endoscopic sphincterotomy procedures in people undergoing laparoscopic cholecystectomy. We excluded other endoscopic or surgical methods of intraoperative clearance of the bile duct, e.g. non-aided intraoperative endoscopic retrograde cholangiopancreatography or laparoscopic choledocholithotomy (surgical incision of the common bile duct for removal of bile duct stones). DATA COLLECTION AND ANALYSIS We used standard methodological procedures recommended by Cochrane. MAIN RESULTS We included five randomised clinical trials with 517 participants (257 underwent a laparoscopic-endoscopic rendezvous technique versus 260 underwent a sequential approach), which fulfilled our inclusion criteria and provided data for analysis. Trial participants were scheduled for laparoscopic cholecystectomy because of suspected cholecysto-choledocholithiasis. Male/female ratio was 0.7; age of men and women ranged from 21 years to 87 years. The run-in and follow-up periods of the trials ranged from 32 months to 84 months. Overall, the five trials were judged at high risk of bias. Athough all trials measured mortality, there was just one death reported in one trial, in the laparoscopic-endoscopic rendezvous group (low-quality evidence). The overall morbidity (surgical morbidity plus general morbidity) may be lower with laparoscopic rendezvous (RR 0.59, 95% CI 0.29 to 1.20; participants = 434, trials = 4; I² = 28%; low-quality evidence); the effect was a little more certain when a fixed-effect model was used (RR 0.56, 95% CI 0.32 to 0.99). There was insufficient evidence to determine the effects of the two approaches on the failure of primary clearance of the bile duct (RR 0.55, 95% CI 0.22 to 1.38; participants = 517; trials = 5; I² = 58%; very low-quality evidence). The effects of either approach on clinical post-operative pancreatitis were unclear (RR 0.29, 95% CI 0.07 to 1.12; participants = 517, trials = 5; I² = 24%; low-quality evidence). Hospital stay appeared to be lower in the laparoscopic-endoscopic rendezvous group by about three days (95% CI 3.51 to 2.50 days shorter; 515 participants in five trials; low-quality evidence). There was very low-quality evidence that suggested longer operative time with laparoscopic-endoscopic rendezvous (MD 34.07 minutes, 95% CI 11.41 to 56.74; participants = 313; trials = 3; I² = 93%). The Trial Sequential Analyses of operating time and the length of hospital stay indicated that all the trials crossed the conventional boundaries, suggesting that the sample sizes were adequate, with a low risk of random error. AUTHORS' CONCLUSIONS There was insufficient evidence to determine the effects of the laparoscopic-endoscopic rendezvous versus preoperative endoscopic sphincterotomy techniques in people undergoing laparoscopic cholecystectomy on mortality and morbidity. The laparoscopic-endoscopic rendezvous procedure may lead to longer operating times, but it may reduce the length of the hospital stay when compared with preoperative endoscopic sphincterotomy followed by laparoscopic cholecystectomy. However, no firm conclusions could be drawn because the quality of evidence was low or very low. If confirmed by future trials, these data might re-design the scenario of treatment of this condition, albeit requiring greater organisational effort. Future trials should also address issues such as quality of life and cost analysis.
Collapse
Affiliation(s)
- Nereo Vettoretto
- ASST Spedali Civili BresciaGeneral Surgery Montichiariv.le Mazzini 4Chiari (BS)Italy25032
| | - Alberto Arezzo
- University of TorinoDepartment of Surgical SciencesCorso Achille Mario Dogliotti 14TurinItaly10126
| | - Federico Famiglietti
- Centre Hospitalier Régional (CHR) Mons‐HainautDepartment of SurgeryAvenue Baudouin de Constantinople 5MonsBelgium7000
| | - Roberto Cirocchi
- University of PerugiaDepartment of General SurgeryTerniItaly05100
| | - Lorenzo Moja
- University of MilanDepartment of Biomedical Sciences for HealthVia Pascal 36MilanSwitzerland20133
| | - Mario Morino
- University of TurinDigestive and Colorectal Surgery, Centre for Minimally Invasive SurgeryCorso Achille Mario Dogliotti 14TurinItaly10126
| | | |
Collapse
|
|
14
|
Mattone E, Latteri S, Teodoro M, Pesce A, Mannino M, Romano G, Russello D, La Greca G. Dystopic retrohepatic gallbladder and cholecysto-choledocho lithiasis: the rendez-vous and indocyanine green fluorescence. Clin Case Rep 2018; 6:522-526. [PMID: 29531732 PMCID: PMC5838276 DOI: 10.1002/ccr3.1130] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 03/22/2017] [Accepted: 04/03/2017] [Indexed: 02/05/2023] Open
Abstract
Laparoscopic cholecystectomy is a well-known procedure for the treatment of most gallbladder diseases. Sometimes, it could be very difficult, in the presence of aberrations regarding the cystic duct, the cystic artery, or the gallbladder itself. Fluorescence laparoscopy using indocyanine green could be very useful for all the situations of anatomy aberrations.
Collapse
Affiliation(s)
- Edoardo Mattone
- U.O.C. di Chirurgia GeneraleAzienda Ospedaliera per l'Emergenza CannizzaroCataniaItaly
| | - Saverio Latteri
- U.O.C. di Chirurgia GeneraleAzienda Ospedaliera per l'Emergenza CannizzaroCataniaItaly
| | - Michele Teodoro
- U.O.C. di Chirurgia GeneraleAzienda Ospedaliera per l'Emergenza CannizzaroCataniaItaly
| | - Antonio Pesce
- U.O.C. di Chirurgia GeneraleAzienda Ospedaliero ‐ Universitaria Policlinico ‐ Vittorio EmanueleCataniaItaly
| | - Maurizio Mannino
- U.O.C. di Chirurgia GeneraleAzienda Ospedaliera per l'Emergenza CannizzaroCataniaItaly
| | - Giulia Romano
- Ospedale Guzzardi Vittoria – U.O. di Medicina InternaVittoriaItaly
| | - Domenico Russello
- U.O.C. di Chirurgia GeneraleAzienda Ospedaliera per l'Emergenza CannizzaroCataniaItaly
| | - Gaetano La Greca
- U.O.C. di Chirurgia GeneraleAzienda Ospedaliera per l'Emergenza CannizzaroCataniaItaly
| |
Collapse
|
|
15
|
Laparoendoscopic rendezvous in the treatment of cholecysto-choledocholitiasis: a single series of 200 patients. Surg Endosc 2018; 32:3868-3873. [PMID: 29488091 DOI: 10.1007/s00464-018-6125-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 02/23/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Although the ideal management of cholecysto-choledocholitiasis is controversial, the two-stage approach, namely the common bile duct (CBD) clearance through endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy, remains the standard way of management. However, whenever feasible, the one-stage approach, using the so-called "laparoendoscopic rendezvous" (LERV) technique, offers some advantages, mainly reducing the hospital stay and the risk of post-ERCP pancreatitis. The aim of this study was to evaluate the safety and the efficacy of the one-stage approach, and to compare our results with data from available large studies. MATERIALS AND METHODS We reviewed our series of consecutive patients with cholecysto-choledocholitiasis treated by LERV from January 2003, to October 2016. Both elective and emergency cases were included. The primary end-point was the efficacy to obtain the CBD stones clearance. Secondary end-points were morbidity and mortality, operative time, conversion rate, and in-hospital stay. RESULTS A total of 200 patients underwent a LERV procedure for the intra-operative diagnosis by intra-operative cholangiogram of cholecysto-choledocholitiasis. In 187 patients (93.5%), it was possible to cannulate the cystic duct with the jag-wire. Success rate was 95%. Conversion rate was 3%. The mean operative time was 135 min and the mean in-hospital stay was 4 days. 29 (14.5%) were the early complications, six mild pancreatitis. Four patients required re-operation during the hospital stay. 11 patients (5.5%) developed late complications during a median follow-up of 57.7 months. CONCLUSIONS Our results confirm that LERV technique is a safe procedure with high success rates for the treatment of cholecysto-choledocholitiasis. The major advantages include the single-stage treatment, the shorter hospital stay, and the lower incidence of post-ERCP pancreatitis.
Collapse
|
|
16
|
Bove A, Di Renzo RM, Palone G, Testa D, Malerba V, Bongarzoni G. Single-stage procedure for the treatment of cholecysto-choledocolithiasis: a surgical procedures review. Ther Clin Risk Manag 2018; 14:305-312. [PMID: 29503549 PMCID: PMC5824758 DOI: 10.2147/tcrm.s146461] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
While laparoscopic cholecystectomy is generally accepted as the treatment of choice for simple gallbladder stones, in cases in which common bile duct stones are also present, clinical and diagnostic elements, along with intraoperative findings, define the optimal means of treatment. All available options must be accessible to the surgical team which must necessarily be multidisciplinary and include a surgeon, an endoscopist, and a radiologist in order to identify the best option for a truly personalized surgery. This review describes the different techniques and approaches used based on distinctive recommendations and factors, according to the specific cases treated and the results achieved.
Collapse
Affiliation(s)
- Aldo Bove
- Department of Medicine, Dentistry and Biotechnology, University “G. d’Annunzio” of Chieti-Pescara, Chieti, Italy
| | - Raffaella Maria Di Renzo
- Department of Medicine, Dentistry and Biotechnology, University “G. d’Annunzio” of Chieti-Pescara, Chieti, Italy
| | - Gino Palone
- Department of Medicine, Dentistry and Biotechnology, University “G. d’Annunzio” of Chieti-Pescara, Chieti, Italy
| | - Domenica Testa
- Department of Medicine, Dentistry and Biotechnology, University “G. d’Annunzio” of Chieti-Pescara, Chieti, Italy
| | - Valentina Malerba
- Department of Medicine, Dentistry and Biotechnology, University “G. d’Annunzio” of Chieti-Pescara, Chieti, Italy
| | - Giuseppe Bongarzoni
- Department of Medicine, Dentistry and Biotechnology, University “G. d’Annunzio” of Chieti-Pescara, Chieti, Italy
| |
Collapse
|
|
17
|
Tarantino G, Magistri P, Ballarin R, Assirati G, Di Cataldo A, Di Benedetto F. Surgery in biliary lithiasis: from the traditional "open" approach to laparoscopy and the "rendezvous" technique. Hepatobiliary Pancreat Dis Int 2017; 16:595-601. [PMID: 29291778 DOI: 10.1016/s1499-3872(17)60031-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Accepted: 12/16/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND According to the current literature, biliary lithiasis is a worldwide-diffused condition that affects almost 20% of the general population. The rate of common bile duct stones (CBDS) in patients with symptomatic cholelithiasis is estimated to be 10% to 33%, depending on patient's age. Compared to stones in the gallbladder, the natural history of secondary CBDS is still not completely understood. It is not clear whether an asymptomatic choledocholithiasis requires treatment or not. For many years, open cholecystectomy with choledochotomy and/or surgical sphincterotomy and cleaning of the bile duct were the gold standard to treat both pathologies. Development of both endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic surgery, together with improvements in diagnostic procedures, influenced new approaches to the management of CBDS in association with gallstones. DATA SOURCES We decided to systematically review the literature in order to identify all the current therapeutic options for CBDS. A systematic literature search was performed independently by two authors using PubMed, EMBASE, Scopus and the Cochrane Library Central. RESULTS The therapeutic approach nowadays varies greatly according to the availability of experience and expertise in each center, and includes open or laparoscopic common bile duct exploration, various combinations of laparoscopic cholecystectomy and ERCP and combined laparoendoscopic rendezvous. CONCLUSIONS Although ERCP followed by laparoscopic cholecystectomy is currently preferred in the majority of hospitals worldwide, the optimal treatment for concomitant gallstones and CBDS is still under debate, and greatly varies among different centers.
Collapse
Affiliation(s)
- Giuseppe Tarantino
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy.
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy; Department of General Surgery, Sapienza-University of Rome, 00189 Rome, Italy
| | - Roberto Ballarin
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Giacomo Assirati
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Antonio Di Cataldo
- Department of Surgical Sciences, Organ Transplantation and Advanced Technologies, University of Catania, 95124 Catania, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy
| |
Collapse
|
|
18
|
Yu M, Xue H, Shen Q, Zhang X, Li K, Jia M, Jia J, Xu J. Primary Closure Following Laparoscopic Common Bile Duct Exploration Combined with Intraoperative Choledochoscopy and D-J Tube Drainage for Treating Choledocholithiasis. Med Sci Monit 2017; 23:4500-4505. [PMID: 28924137 PMCID: PMC5616138 DOI: 10.12659/msm.903753] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 03/21/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND This study aimed to assess the clinical short-term results of a primary closure following laparoscopic common bile duct exploration (LCBDE) combined with intraoperative choledochoscopy and D-J tube drainage for choledocholithiasis treatment. MATERIAL AND METHODS Twenty-five patients (14 women and 11 men) who underwent LCBDE with primary duct closure and D-J tube drainage for choledocholithiasis were retrospectively enrolled. The D-J tube (4.7F×14 cm) was removed using a duodenoscope if there was no bile leakage. Before discharge, patients were examined for blood amylase. After discharge or D-J tube removal, all patients were routinely assessed for complications. RESULTS Mean operating time was 135±46 min (range, 78-195 min). Mean intraoperative blood loss was 71±24 mL (range, 25-110 mL). Total hospital stay was 6-9 days (mean, 8.04±1.37 days). Two patients experienced intraoperative bile leakage, which was stopped with re-suturing. None of these patients experienced postoperative bile leaks. Three patients had slight elevation of serum amylase before discharge but without pancreatitis signs. The successful clearance rate of stones was 100%. During 1-year follow-up, no recurrence or severe complications occurred. CONCLUSIONS A primary closure following LCBDE combined with intraoperative choledochoscopy and D-J tube drainage is safe and feasible for choledocholithiasis treatment.
Collapse
|
|
19
|
La Greca G, Pesce A, Vitale M, Mannino M, Di Marco F, Di Blasi M, Lombardo R, Puleo S, Russello D, Latteri S. Efficacy of the Laparoendoscopic "Rendezvous" to Treat Cholecystocholedocholithiasis in 210 Consecutive Patients: A Single Center Experience. Surg Laparosc Endosc Percutan Tech 2017; 27:e48-e52. [PMID: 28614175 DOI: 10.1097/sle.0000000000000434] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The simultaneous laparoendoscopic "rendezvous" (LERV) represents an alternative to sequential or totally laparoscopic approaches for patients affected by cholecystocholedocholithiasis. The aim of this study was to analyze the results in a large series of 210 consecutive patients. MATERIALS AND METHODS From 2002 to 2016 all patients affected by cholecystocholedocholithiasis were treated with a standardized "tailored" LERV. The relevant technical features of the procedure were recorded. An analysis of feasibility, effectiveness in stone clearance, and safety was performed. RESULTS Among 214 patients with common bile duct stones, 210 were treated with LERV and 4 with open rendezvous approach. Intraoperative cholangiography confirmed common bile duct stones in 179 patients (85.2%) or sludge in 18 (8.5%) and in 98.9% stone clearance was obtained endoscopically. Endoscopic papilla cannulation was feasible in 161 patients (76.7%), whereas in 49 (23.3%) a transcystic guidewire was needed. The overall LERV feasibility was 96.6%. The conversion rate to open surgery was 3.3%. Minor morbidity was observed in 1.9% of cases, mortality in 0.47%, and the mean hospital stay was 4.3 days. CONCLUSIONS These results confirm the high effectiveness of LERV. This approach to treat cholecystocholedocholithiasis should be preferred and therefore implemented where a strong collaboration between surgeons and endoscopists is possible.
Collapse
Affiliation(s)
- Gaetano La Greca
- *Department of Medical, Surgical Sciences and Advanced Technologies "G.F. Ingrassia," University of Catania †Endoscopic Unit, Cannizzaro Hospital, Catania, Italy
| | | | | | | | | | | | | | | | | | | |
Collapse
|
|
20
|
Comparison of one stage laparoscopic cholecystectomy combined with intra-operative endoscopic sphincterotomy versus two-stage pre-operative endoscopic sphincterotomy followed by laparoscopic cholecystectomy for the management of pre-operatively diagnosed patients with common bile duct stones: a meta-analysis. Surg Endosc 2017; 32:770-778. [PMID: 28733744 DOI: 10.1007/s00464-017-5739-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 07/14/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) for symptomatic gallstone disease is one of the most common surgical procedures. Concomitant common bile duct (CBD) stones are detected with an incidence of 4-20% and the ideal management is still controversial. The frequent practice is to perform endoscopic sphincterotomy pre-operatively (POES) followed by LC, to allow subsequent laparoscopic or open exploration if POES fails. However, POES has shown different drawbacks such as need for two hospital admissions, need of two anesthesia inductions, higher rate of pancreatitis, and longer hospital stay. Hence, an intra-operative endoscopic sphincerotomy (IOES) has been proposed. OBJECTIVE To compare the 1 stage laparoscopic cholecystectomy (LC) combined with IOES versus 2-stage POES followed by LC for the management of pre-operatively known cholecystocholedocholithiasis. SEARCH STRATEGY The search terms bile duct stones/calculi, ERCP, endoscopic sphincterotomy, laparoendoscopic rendezvous (LERV), and laparoscopic ductal clearance/choledochotomy/exploration were used. A comprehensive hand-based search of reference lists of published articles and review articles was performed to ensure inclusion of all possible studies and exclude duplicates. SELECTION CRITERIA RCTs comparing 1 stage LC combined with IOES versus 2-stage POES followed by LC for the management of pre-operatively known cholecystocholedocholithiasis in adults. DATA COLLECTION & ANALYSIS Three reviewers assessed trial quality and extracted the data. Data were entered in revman version 5.3. The trials were grouped according to the outcome measure assessed such as success rate of CBD stone clearance, incidence of pancreatitis, overall morbidity, and length of hospital stay. MAIN RESULTS A total of 629 patients in 5 RCTs met the inclusion criteria. The success rate of CBD clearance (IOES = 93%, POES = 92%) was the same in both groups (OR 1.34; 95% CI 0.45-0.97; p = 0.60). Findings showed that IOES was associated with less pancreatitis (0.6%) than POES (4.4%) (OR 0.19; 95% CI 0.06-0.67; p = 0.01; I 2 = 43%). The incidence of overall morbidity was lower in the IOES group (6%) than the POES group (11%) (OR 0.54; 95% CI 0.31-0.96; p = 0.03; I 2 = 20%). The mean days of hospital stay for IOES group (M = 3.52, SD = 1.434, N = 5) was significantly less than the POES group (M = 6.10, SD = 2.074, N = 5), t(8) = 2.29, p <= 0.051. CONCLUSION IOES is at par with two-stage POES in terms of CBD clearance, with less incidence of post-operative pancreatitis, overall morbidity, and less hospital stay.
Collapse
|
|
21
|
Garbarini A, Reggio D, Arolfo S, Bruno M, Passera R, Catalano G, Barletti C, Salizzoni M, Morino M, Petruzzelli L, Arezzo A. Cost analysis of laparoendoscopic rendezvous versus preoperative ERCP and laparoscopic cholecystectomy in the management of cholecystocholedocholithiasis. Surg Endosc 2016; 31:3291-3296. [DOI: 10.1007/s00464-016-5361-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 11/13/2016] [Indexed: 01/15/2023]
|
|
22
|
Barreras González JE, Torres Peña R, Ruiz Torres J, Martínez Alfonso MÁ, Brizuela Quintanilla R, Morera Pérez M. Endoscopic versus laparoscopic treatment for choledocholithiasis: a prospective randomized controlled trial. Endosc Int Open 2016; 4:E1188-E1193. [PMID: 27857966 PMCID: PMC5111834 DOI: 10.1055/s-0042-116144] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and study aims: Overall, 5 % to 15 % of patients undergoing cholecystectomy for cholelithiasis have concomitant bile duct stones, and the incidence of choledocholithiasis increases with age. There is no clear consensus on the best therapeutic approach (endoscopic versus surgical). Patients and methods: A prospective randomized controlled clinical trial was performed to compare three treatment options for patients with choledocholithiasis at the National Center for Minimally Invasive Surgery in Havana, Cuba from November 2007 to November 2011. The patients were randomized in three groups. Group I: patients who underwent intraoperative cholangiography (IOC) to confirm the choledocholithiasis followed by laparoscopic cholecystectomy (LC) associated with intraoperative endoscopic retrograde cholangiopancreatography (ERCP), group II: patients who underwent preoperative ERCP followed by LC during the same hospital admission and group III: patients who underwent IOC to confirm the choledocholithiasis followed by LC associated with laparoscopic common bile duct exploration (LCBDE). Results: A total of 300 patients with suspected choledocholithiasis were included in the trial and were randomized. As a result, a total of 134 patients were diagnosed with the presence of choledocholithiasis and treated during the study period. There were no significant differences in success rates of ductal stone clearance, but retained stone, postoperative complications and length of hospital stay were better in group I. Conclusions: Intraoperative ERCP/ES shows a higher rate of common bile duct stones clearance, a shorter hospital stay, and lower morbidity, but further research with a larger study population is necessary to determine the additional benefits of this procedure. The results to date suggests that in appropriate patients, single-stage treatments are the best options.
Collapse
Affiliation(s)
- Javier Ernesto Barreras González
- Department of Laparoscopic and Endoscopic Surgery, National Center for
Minimally Invasive Surgery, Havana Medical University, Havana, Cuba.,Corresponding author Javier Ernesto Barreras González, MD, PhD Department of Laparoscopic and Endoscopic SurgeryNational Center for Minimally Invasive SurgeryPárraga Street b/ San Mariano and Vista AlegreLa Víbora10 de OctubreHavanaCuba+537-649-0150
| | - Rafael Torres Peña
- Department of Laparoscopic and Endoscopic Surgery, National Center for
Minimally Invasive Surgery, Havana Medical University, Havana, Cuba.
| | - Julián Ruiz Torres
- Department of Laparoscopic and Endoscopic Surgery, National Center for
Minimally Invasive Surgery, Havana Medical University, Havana, Cuba.
| | - Miguel Ángel Martínez Alfonso
- Department of Laparoscopic and Endoscopic Surgery, National Center for
Minimally Invasive Surgery, Havana Medical University, Havana, Cuba.
| | - Raúl Brizuela Quintanilla
- Department of Laparoscopic and Endoscopic Surgery, National Center for
Minimally Invasive Surgery, Havana Medical University, Havana, Cuba.
| | - Maricela Morera Pérez
- Department of Laparoscopic and Endoscopic Surgery, National Center for
Minimally Invasive Surgery, Havana Medical University, Havana, Cuba.
| |
Collapse
|
|
23
|
Yu A, Huang Q, Liu CH, Lin XS, Xie F. Rendezvous technique for cholecysto-choledocholithiasis during laparoscopic cholecystectomy: A systemic review and meta-analysis. Shijie Huaren Xiaohua Zazhi 2016; 24:2563-2570. [DOI: 10.11569/wcjd.v24.i16.2563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AIM: To systematically evaluate the efficacy and safety of the rendezvous technique for cholecysto-choledocholithiasis during laparoscopic cholecystectomy (LC).
METHODS: From February 31, 2006 to February 31, 2016, RCTs evaluating the rendezvous technique for cholecysto-choledocholithiasis during laparoscopic cholecystectomy were retrieved from Cochrane Library, PubMed, Embase, CBM, CNKI database, Wanfang and VIP database. The data were extracted and analyzed using the RevMan 5.3.5 software.
RESULTS: Six RCTs were enrolled in the meta-analysis. Among 616 patients analyzed, the rendezvous technique was used in 307 patients and POERCP + LC in 309 patients. The results of meta-analysis showed significant differences between the rendezvous technique group and POERCP + LC group regarding stone clearance rate (OR = 2.24, 95%CI: 1.26-4.65, P = 0.08), cannulation failure rate (OR = 0.39, 95%CI: 0.18-0.83, P = 0.01), and overall morbidity (OR = 0.41, 95%CI: 0.22-0.75, P = 0.004). Sub-group analysis of morbidity also revealed significant differences between the rendezvous technique group and POERCP + LC group regarding post-ERCP pancreatitis (OR = 0.15, 95%CI: 0.05-0.44, P = 0.0005) and hyperamylasemia (OR = 0.18, 95%CI: 0.09-0.36, P = 0.0001), but the differences in the complication morbidity of LC and conversions rate were not significant (P > 0.05).
CONCLUSION: The rendezvous technique is superior to POERCP + LC in terms of stone clearance, cannulation success, complication morbidity of ERCP and hospital stay. Large, multicenter prospective randomized controlled trials are still needed to confirm the findings of this meta-analysis.
Collapse
|
|
24
|
Cantù P, Parzanese I, Melada E, Rossi G, Conte D, Penagini R. Response. Gastrointest Endosc 2016; 83:1304. [PMID: 27206598 DOI: 10.1016/j.gie.2016.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 02/15/2016] [Indexed: 02/08/2023]
Affiliation(s)
- Paolo Cantù
- Gastroenterology and Endoscopy Unit, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Ilaria Parzanese
- Gastroenterology and Endoscopy Unit, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Ernesto Melada
- Liver Transplant Unit, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Giorgio Rossi
- Liver Transplant Unit, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Dario Conte
- Gastroenterology and Endoscopy Unit, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| |
Collapse
|
|
25
|
Ibrarullah M, Mishra T, Dash AP, Mohapatra D, Modi MS. 'Single-Sitting' Laparoscopic Cholecystectomy and Endoscopic Removal of Common Bile Duct Stone for Cholelithiasis and Choledocholithiasis: a Feasibility Study. Indian J Surg 2016; 77:708-11. [PMID: 26730094 DOI: 10.1007/s12262-013-0937-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 06/13/2013] [Indexed: 01/12/2023] Open
Abstract
'Single-sitting' laparoscopic cholecystectomy followed by endoscopic common bile duct clearance is emerging as a viable option for management of cholelithiasis and concomitant choledocholithiasis. The only disadvantage of the procedure is logistical since it requires co-ordination between two teams-the surgeons and the endoscopists. This limitation can be overcome in centres where both the procedures are performed by one team. With a considerable experience in endoscopy, we conducted a prospective study in a select group of patients to assess the feasibility of this single-sitting approach. The study included 38 patients with a radiological diagnosis of choledocholithiasis or jaundice at presentation. After laparoscopic cholecystectomy, the patients were turned prone and subjected to endoscopic retrograde cholangiogram, sphincterotomy and extraction of the common bile duct stone. The procedure was successful in 33 (87 %) of patients. The mean procedure time and hospital stay were 2 h, 20 min and 2 days, respectively. None of the patients had any major complications. We conclude that in a select group of patients, single-sitting laparoscopic cholecystectomy followed by endoscopic clearance of the common bile duct stone is safe and effective.
Collapse
Affiliation(s)
- Md Ibrarullah
- Department of Surgical Gastroenterology, Apollo Hospitals, Bhubaneswar, 751005 Odisha India
| | - Tapas Mishra
- Department of Surgery, Hitech Medical College, Bhubaneswar, 751023 Odisha India
| | - Ambika P Dash
- Department of Surgery, Hitech Medical College, Bhubaneswar, 751023 Odisha India
| | - Devanand Mohapatra
- Department of Medicine, Hitech Medical College, Bhubaneswar, 751023 Odisha India
| | - M S Modi
- Department of Surgical Gastroenterology, Apollo Hospitals, Bhubaneswar, 751005 Odisha India
| |
Collapse
|
|
26
|
Borreca D, Bona A, Bellomo MP, Borasi A, De Paolis P. “Ultra-rapid” sequential treatment in cholecystocholedocholithiasis: alternative same-day approach to laparoendoscopic rendezvous. Updates Surg 2015; 67:449-54. [DOI: 10.1007/s13304-015-0339-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Accepted: 11/26/2015] [Indexed: 12/21/2022]
|
|
27
|
Bove A, Di Renzo RM, Palone G, D'Addetta V, Caldararo F, Antonopulos C, Panaccio P, Chiarini S, Bongarzoni G. Which differences do elderly patients present in single-stage treatment for cholecysto-choledocholithiasis? Int J Surg 2014; 12 Suppl 2:S160-S163. [PMID: 25157986 DOI: 10.1016/j.ijsu.2014.08.358] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 06/15/2014] [Indexed: 02/03/2023]
Abstract
Patients with symptomatic gallstones present common bile duct stones in approximately 10% of cases. It is possible to resolve both gallbladder and bile duct stones with a single procedure. The aim of this study is to determine the effectiveness of a single stage procedure for gallbladder and bile duct stones in the elderly patients and to expose the differences between the various techniques. From January 2008 to December 2013, we treated 1540 patients with gallbladder stones. In 152 cases, we also found bile duct stones. 150 of these were treated in a single stage procedure. We divided our patients into 2 groups: Group A was younger than 65 (104 patients); Group B was 65 or older (46 patients). We retrospectively compared sex, ASA score, conversion rate, success rate, post-operative complications, hospital stay, and treatment method. We had no intra-operative mortality. 1 patient in Group B, heart condition (ASA 4), died with multiple organ failure (MOF) 10 days after his operation. ASA score: 3.5 ± 0.5 in A vs 2 ± 0.9 in B (P 0.001), post-operative complications 6% in A vs 18.1% in B (P 0.0325) and hospital stay 4.1 ± 2.3 in A vs 9.5 ± 5.5 in B (P 0.0001) were significantly higher in Group B. No differences were found in term of success rate: 94% in A vs 90% in B (P 0.4944). The procedure used to obtain the clearance of the bile duct showed a different success rate across the two groups: for the patients under 65 years old, trans-cystic clearance (TC-CBDE) was successful in 90% of cases, and only 51% for those older than 65, where we had to recall 49% for laparo-endoscopic rendez-vous (RV-IOERC) (P 0.0014). In conclusion, single stage treatment is safe and effective also to elderly patients. The methods used in patients being younger than 65 years old is what appeared to be significantly different.
Collapse
Affiliation(s)
- A Bove
- Department of Experimental and Clinical Sciences, University " G.D'Annunzio", Chieti-Pescara, Italy.
| | - R M Di Renzo
- Department of Experimental and Clinical Sciences, University " G.D'Annunzio", Chieti-Pescara, Italy.
| | - G Palone
- Department of Experimental and Clinical Sciences, University " G.D'Annunzio", Chieti-Pescara, Italy.
| | - V D'Addetta
- Department of Experimental and Clinical Sciences, University " G.D'Annunzio", Chieti-Pescara, Italy.
| | - F Caldararo
- Department of Experimental and Clinical Sciences, University " G.D'Annunzio", Chieti-Pescara, Italy.
| | - C Antonopulos
- Department of Experimental and Clinical Sciences, University " G.D'Annunzio", Chieti-Pescara, Italy.
| | - P Panaccio
- Department of Experimental and Clinical Sciences, University " G.D'Annunzio", Chieti-Pescara, Italy.
| | - S Chiarini
- Department of Medicine and Aging Sciences, University " G.D'Annunzio", Chieti-Pescara, Italy.
| | - G Bongarzoni
- Department of Experimental and Clinical Sciences, University " G.D'Annunzio", Chieti-Pescara, Italy.
| |
Collapse
|
|
28
|
A modified technique reduced operative time of laparoendoscopic rendezvous endoscopic retrograde cholangiopancreatography combined with laparoscopic cholecystectomy for concomitant gallstone and common bile ductal stone. Gastroenterol Res Pract 2014; 2014:861295. [PMID: 25024701 PMCID: PMC4082838 DOI: 10.1155/2014/861295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 05/13/2014] [Accepted: 05/23/2014] [Indexed: 01/11/2023] Open
Abstract
Laparoendoscopic rendezvous (LERV) endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC+ERCP/LERV) are considered an optimal approach for concomitant gallstones and common bile duct stones. The rendezvous technique is essential for the success of procedure. We applied two different LERV techniques, traditional technique and modified technique, in 60 consecutive cases from January 2011 to November 2012. 32 cases who underwent modified technique (group 1) from February 2012 to November 2012 were retrospectively compared to 28 cases (group 2) who underwent traditional technique from January 2011 to January 2012. There was no significant difference between two groups with respect to preoperative demographic features. Although the difference was not statistically significant, the procedure was successfully performed in 31 cases (96.9%) in group 1 and 24 cases (86.2%) in group 2. The mean operative time and time of endoscopic part were 82.6 ± 19.6 min and 26.5 ± 5.99 min in group 1 which were significantly shorter than those in group 2 (118.0 ± 23.1 min and 58.7 ± 13.3 min, resp.). There was no postoperative pancreatitis and mortality in both groups. The mean hospital stay, blood loss, incidence of complications, and residual stone were of no difference in both groups. This study proved that this modified technique can effectively reduce the operative time and time of endoscopic part of LC+ERCP/LERV compared with traditional technique.
Collapse
|
|
29
|
Swahn F, Regnér S, Enochsson L, Lundell L, Permert J, Nilsson M, Thorlacius H, Arnelo U. Endoscopic retrograde cholangiopancreatography with rendezvous cannulation reduces pancreatic injury. World J Gastroenterol 2013; 19:6026-34. [PMID: 24106403 PMCID: PMC3785624 DOI: 10.3748/wjg.v19.i36.6026] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 03/13/2013] [Accepted: 03/21/2013] [Indexed: 02/07/2023] Open
Abstract
AIM: To examine whether rendezvous endoscopic retrograde cholangiopancreatography (ERCP) is associated with less pancreatic damage, measured as leakage of proenzymes, than conventional ERCP.
METHODS: Patients (n = 122) with symptomatic gallstone disease, intact papilla and no ongoing inflammation, were prospectively enrolled in this case-control designed study. Eighty-one patients were subjected to laparoscopic cholecystectomy and if intraoperative cholangiography suggested common bile duct stones (CBDS), rendezvous ERCP was performed intraoperatively (n = 40). Patients with a negative cholangiogram constituted the control group (n = 41). Another 41 patients with CBDS, not subjected to surgery, underwent conventional ERCP. Pancreatic proenzymes, procarboxypeptidase B and trypsinogen-2 levels in plasma, were analysed at 0, 4, 8 and 24 h. The proenzymes were determined in-house with a double-antibody enzyme linked immunosorbent assay. Pancreatic amylase was measured by an enzymatic colourimetric modular analyser with the manufacturer’s reagents. All samples were blinded at analysis.
RESULTS: Post ERCP pancreatitis (PEP) occurred in 3/41 (7%) of the patients cannulated with conventional ERCP and none in the rendezvous group. Increased serum levels indicating pancreatic leakage were significantly higher in the conventional ERCP group compared with the rendezvous ERCP group regarding pancreatic amylase levels in the 4- and 8-h samples (P = 0.0015; P = 0.03), procarboxypeptidase B in the 4- and 8-h samples (P < 0.0001; P < 0.0001) and trypsinogen-2 in the 24-hour samples (P = 0.03). No differences in these markers were observed in patients treated with rendezvous cannulation technique compared with patients that underwent cholecystectomy alone (control group). Post procedural concentrations of pancreatic amylase and procarboxypeptidase B were significantly correlated with pancreatic duct cannulation and opacification.
CONCLUSION: Rendezvous ERCP reduces pancreatic enzyme leakage compared with conventional ERCP cannulation technique. Thus, laparo-endoscopic technique can be recommended with the ambition to minimise the risk for post ERCP pancreatitis.
Collapse
|
|
30
|
Tommasi C, Bencini L, Bernini M, Naspetti R, Cavallina G, Manetti R, Talamucci L, Farsi M. Routine use of simultaneous laparoendoscopic approach in patients with confirmed gallbladder and bile duct stones: fit for laparoscopy fit for "rendezvous". World J Surg 2013; 37:999-1005. [PMID: 23430003 DOI: 10.1007/s00268-013-1962-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of the present work was to determine the feasibility and efficacy, in terms of equipment coordination and timing, of the laparoendoscopic intraoperative rendezvous technique (RVT) for the treatment of gallbladder and common bile duct stones (CBDS). METHODS The procedure was considered in 269 unselected patients with a suspicion or preoperative imaging demonstration of CBDS who were fit for laparoscopic cholecystectomy (LC). Common bile duct stones were confirmed by intraoperative laparoscopic cholangiography (IOC) in only 113 of these patients (42 %). In 17 (15 %) patients the planned procedure was aborted because of organizational problems, mainly the unavailability of endoscopists in the urgent setting. The remaining 96 patients (84 %) underwent a formal attempt at RVT. Intraoperative endoscopic retrograde cholangiography (ERC) was performed, during LC, by means of a guidewire that reached the duodenum through the cystic duct. RESULTS In 18 patients (19 %) the complete procedure failed, either because of difficulty in passing the guidewire through the papilla or because of other technical difficulties that required conversion to laparotomy. An intraoperative ERC was completed in six patients in the classical way (no guidewire) without conversion. No mortality and few complications were recorded (3 % overall: 1 perforation and 2 cholangitis). Retained stones were successively detected in 6 patients (6 %) and successfully retreated by a further ERC. Globally, the one-stage procedure (with and without the guidewire) was possible in 84 of 96 patients (87 %). CONCLUSIONS The RVT appears to be effective and safe as it was performed at our institution, with an overall percentage of definitive success (passed guide wire and no further ERC) of 81 %. The RVT should be considered as a good option for the treatment of simultaneous gallstones and CBDS.
Collapse
Affiliation(s)
- Cinzia Tommasi
- Surgical Oncology, Surgical and Flexible Endoscopic Unit, Careggi University Hospital, Largo Brambilla 3, Florence, Italy
| | | | | | | | | | | | | | | |
Collapse
|
|
31
|
Vettoretto N, Arezzo A, Famiglietti F, Cirocchi R, Moja L, Morino M. Laparoscopic-endoscopic rendezvous versus preoperative endoscopic sphincterotomy for common bile duct stones in patients undergoing laparoscopic cholecystectomy. Cochrane Database Syst Rev 2013. [DOI: 10.1002/14651858.cd010507] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Nereo Vettoretto
- AO Mellini; Laparoscopic Surgical Unit; v.le Mazzini 4 Chiari (BS) Italy 25032
| | - Alberto Arezzo
- University of Turin; Digestive and Colorectal Surgery, Centre for Minimally Invasive Surgery; Corso Achille Mario Dogliotti 14 Turin Italy 10126
| | - Federico Famiglietti
- University of Turin; Digestive and Colorectal Surgery, Centre for Minimally Invasive Surgery; Corso Achille Mario Dogliotti 14 Turin Italy 10126
| | - Roberto Cirocchi
- University of Perugia; Department of General Surgery; Terni Italy
| | - Lorenzo Moja
- University of Milan - IRCCS Galeazzi Orthopedic Institute; Department of Biomedical Sciences for Health; Via Pascal 36 Milan Italy 20133
| | - Mario Morino
- University of Turin; Digestive and Colorectal Surgery, Centre for Minimally Invasive Surgery; Corso Achille Mario Dogliotti 14 Turin Italy 10126
| |
Collapse
|
|
32
|
Ding YB, Deng B, Liu XN, Wu J, Xiao WM, Wang YZ, Ma JM, Li Q, Ju ZS. Synchronous vs sequential laparoscopic cholecystectomy for cholecystocholedocholithiasis. World J Gastroenterol 2013; 19:2080-2086. [PMID: 23599628 PMCID: PMC3623986 DOI: 10.3748/wjg.v19.i13.2080] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 01/04/2013] [Accepted: 01/11/2013] [Indexed: 02/06/2023] Open
Abstract
AIM To compare synchronous laparoscopic cholecystectomy (LC) combined with endoscopic sphincterotomy (EST) and sequential LC combined with EST for treating cholecystocholedocholithiasis. METHODS A total of 150 patients were included and retrospectively studied. Among these, 70 were selected for the synchronous operation, in which the scheme was endoscopic retrograde cholangiopancreatography combined with EST during LC. The other 80 patients were selected for the sequential operation, in which the scheme involved first cutting the papillary muscle under endoscopy and then performing LC. The indexes in the two groups, including the operation time, the success rate, the incidence of complications, and the length of the hospital stay, were observed. RESULTS There were no significant differences between the groups in terms of the numbers of patients, sex distribution, age, American Society of Anesthesiologists score, serum bilirubin, γ-glutamyl transpeptidase, mean diameter of common bile duct stones, and previous medical and surgical history (P = 0.54, P = 0.18, P = 0.52, P = 0.22, P = 0.32, P = 0.42, P = 0.68, P = 0.70, P = 0.47 and P = 0.57). There was no significant difference in the surgical operation time between the two groups (112.1 ± 30.8 min vs 104.9 ± 18.2 min). Compared with the sequential operation group, the incidence of pancreatitis was lower (1.4% vs 6.3%), the incidence of hyperamylasemia (1.4% vs 10.0%, P < 0.05) was significantly reduced, and the length of the hospital stay was significantly shortened in the synchronous operation group (3 d vs 4.5 d, P < 0.001). CONCLUSION For treatment of cholecystocholedocholithiasis, synchronous LC combined with EST reduces incidence of complications, decreases length of hospital stay, simplifies the surgical procedure, and reduces operation time.
Collapse
|
|
33
|
Rendezvous cannulation technique reduces post-ERCP pancreatitis: a prospective nationwide study of 12,718 ERCP procedures. Am J Gastroenterol 2013; 108:552-9. [PMID: 23419386 DOI: 10.1038/ajg.2012.470] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The aim of this study was to investigate if intraoperative rendezvous cannulation reduces the risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) because there is no universal consensus on the optimal treatment of common bile duct stones. METHODS We performed a nationwide case-control study, nested within the cohort of ERCP procedures reported to the Swedish Registry for Gallstone Surgery and ERCP (GallRiks), between 2007 and 2009. Data were collected prospectively from a web-based registry of ERCP procedures that includes variables such as patient characteristics, indication, cannulation technique, diagnostic findings, therapeutic measures, and complications. The primary outcome was PEP. RESULTS The registry included 12,718 ERCP procedures performed on patients without a history of previous ERCP. The risk of PEP when using the rendezvous technique compared with those who were cannulated by conventional means was reduced from 3.6 to 2.2% (odds ratio (OR) 0.5, 95% confidence interval 0.2-0.9, P=0.02). Although a significant reduction there are overall relatively few cases with PEP and the calculated numbers needed to treat to avoid one case of PEP is as high as 71. Other factors associated with increased risk of PEP were young age, prolonged procedure time, and elective ERCP. CONCLUSIONS Rendezvous bile duct cannulation during ERCP reduces the risk of PEP from 3.6 to 2.2% compared with conventional biliary cannulation.
Collapse
|
|
34
|
Noel R, Enochsson L, Swahn F, Löhr M, Nilsson M, Permert J, Arnelo U. A 10-year study of rendezvous intraoperative endoscopic retrograde cholangiography during cholecystectomy and the risk of post-ERCP pancreatitis. Surg Endosc 2013; 27:2498-503. [PMID: 23355164 DOI: 10.1007/s00464-012-2768-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 12/10/2012] [Indexed: 12/27/2022]
Abstract
BACKGROUND Rendezvous intraoperative endoscopic retrograde cholangiography (RV-IOERC), also called guidewire-facilitated IOERC, is one of the single-stage options available for managing common bile duct stones (CBDS) during laparoscopic cholecystectomy. The objective of this study is to investigate procedure-related complications in IOERC patients and stone clearance. METHODS All patients who underwent IOERC between January 2000 and December 2009 were identified from the local registry of Karolinska University Hospital in Huddinge. Medical charts and ERC reports were studied, and descriptive statistics were obtained. Outcomes were procedure-related complications, especially post-ERCP pancreatitis (PEP), stone clearance, and mortality. RESULTS 307 patients were identified. In 264 of the patients, the rendezvous cannulation technique was successful (86 %); in the remaining 43 patients, conventional cannulation technique was necessary. In total, PEP occurred in seven patients (2.28 %). One of the PEP patients was in the rendezvous cannulated group (0.37 %), whereas six patients developed PEP in the nonrendezvous group (13.95 %, p < 0.001). The primary stone clearance rate was 88.27 % (271/307). There was no mortality within 90 days in the series. CONCLUSIONS IOERC with RV cannulation technique for management of CBDS during laparoscopic cholecystectomy has a low PEP rate and a high stone clearance rate, making it a safe and feasible method for removing CBDS. However, the technique requires logistics to perform IOERC in the operating theater. The present data suggest that IOERC with RV cannulation is superior to conventional cannulation with respect to risk of PEP.
Collapse
Affiliation(s)
- Rozh Noel
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockhom, Sweden.
| | | | | | | | | | | | | |
Collapse
|
|
35
|
Preoperative versus intraoperative endoscopic sphincterotomy in patients with gallbladder and suspected common bile duct stones: system review and meta-analysis. Surg Endosc 2013; 27:2454-65. [PMID: 23355158 DOI: 10.1007/s00464-012-2757-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2012] [Accepted: 11/24/2012] [Indexed: 12/22/2022]
Abstract
BACKGROUND Conducting preoperative versus intraoperative endoscopic sphincterotomy in patients with gallbladder and suspected common bile duct stones remains controversial. We conducted a meta-analysis to evaluate the outcomes of preoperative endoscopic sphincterotomy (POES) versus intraoperative endoscopic sphincterotomy (IOES). METHODS We searched multiple electronic databases for prospective, randomized, controlled trials related to safety and effectiveness of POES versus IOES. Relative risk ratios (RRs) were estimated with 95 % confidence intervals (CI) based on an intention-to-treat analysis. We considered the following outcomes: clearance rate, postprocedural complications, and hospital stay. RESULTS Five trials with 631 patients (318 with POES, 313 with IOES) were analyzed. Although the overall rates of common bile duct stone clearance were similar between POES and IOES (RR 0.96, 95 % CI 0.91-1.01; p = 0.13), the failure rate of common bile duct cannulation during endoscopic retrograde cholangiopancreatography (ERCP) was significantly higher for IOES (RR 2.54, 95 % CI 1.23-5.26; p = 0.01). The pooled RR after POES for overall complication rates was similar to that for IOES (RR 1.56, 95 % CI 0.94-2.59; p = 0.09). However, compared with IOES, the RR risk of ERCP-related complications was significantly higher for POES (RR 2.27, 95 % CI 1.18-4.40, p = 0.01), especially in the patients at high risk of developing post-ERCP pancreatitis. There was no significant difference in morbidity after laparoscopic cholecystectomy or required subsequent open surgery between the two groups. In the subgroup analyses, the RR risks of post-ERCP pancreatitis were significantly higher for POES (RR 4.85, 95 % CI 1.41-16.66, p = 0.01), and mean hospital stay was longer in the POES group (RR 2.22, 95 % CI 1.98-246; p < 0.01). However, the rates of bleeding, perforation, cholangitis, cholecystitis, and gastric ulceration did not differ significantly between POES and IOES. CONCLUSIONS With regard to the stone clearance and overall complication rates, POES is equal to IOES in patients with gallbladder and common bile duct stones. However, IOES is associated with a reduced incidence of ERCP-related pancreatitis and results in a shorter hospital stay.
Collapse
|
|
36
|
Pereira-Graterol F, Venales-Barrios Y, Bousquet-Suárez J, Cáceres-Cauro A, Romero-Bravo C, Moreno-Rodríguez J, Rodríguez-Perero L. [The "rendez-vous" maneuver as a technical option to access the bile ducts: case series report]. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2012; 77:224-8. [PMID: 23153415 DOI: 10.1016/j.rgmx.2012.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Revised: 04/01/2012] [Accepted: 04/03/2012] [Indexed: 11/15/2022]
Abstract
The "rendez-vous" maneuver is a technical option, to have in mind, for the bile ducts access. This technique assures a "guided" canulation of the bile duct during the laparoscopic cholecystectomy (LC). We analyzed three clinical cases of patients with cholecysto-choledocolithiasis, in whose were planned Endoscopic Retrograde Cholangio-Pancreatography (ERCP) and LC during the same surgical intervention. The "rendez-vous" maneuver was employed as a technical option to access the bile duct, after an initial (failed) endoscopic attempt of cannulation. An intraoperative cholangiography was performed and a guide wire was inserted through the cystic duct, allowing the endoscopic capture and the guided cannulation of the bile duct. The therapeutic objective was achieved in all patients. There was not associated morbid-mortality and all patients were satisfied with the surgical outcome. In these series of cases, the "rendez-vous" maneuver was a viable, safe and useful technical option to access the bile ducts. Futhermore, the cholecysto-choledocolithiasis was treated during the same surgical intervention. A postoperative bile duct exploration becomes unnecessary.
Collapse
Affiliation(s)
- F Pereira-Graterol
- Unidad de Cirugía de Mínimo Acceso (UCMA), Hospital Universitario "Dr. Luis Razetti", Barcelona, Venezuela.
| | | | | | | | | | | | | |
Collapse
|
|
37
|
Laparoendoscopic rendezvous reduces perioperative morbidity and risk of pancreatitis. Surg Endosc 2012; 27:1055-60. [PMID: 23052536 DOI: 10.1007/s00464-012-2562-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2012] [Accepted: 08/16/2012] [Indexed: 12/19/2022]
Abstract
BACKGROUND The ideal management of cholelithiasis and common bile duct stones still is controversial. Although the two-stage sequential approach remains the prevalent management, several trials have concluded that the so-called laparoendoscopic rendezvous (LERV) technique offers some advantages, such as a reduced risk of post-ERCP (endoscopic retrograde cholangiopancreatography) pancreatitis. This study aimed to compare the single-stage LERV technique with the two-stage endoscopic sphincterotomy followed by laparoscopic cholecystectomy. METHODS A search for randomized controlled trials (RCTs) comparing LERV and the two-stage sequential approach was conducted. The outcomes considered were overall complications and pancreatitis. Medline, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from 1998 to July 2012. Odds ratios (ORs) were extracted and pooled using a fixed or random-effect model depending on I (2) used as a heterogeneity measure. RESULTS Four RCTs, including a total of 430 patients, met the inclusion criteria. The incidence of overall complications was lower in the LERV group (11.2 %) than in the two-stage intervention group (18.1 %) (OR, 0.56; 95 % confidence interval [CI], 0.32-0.99; P = 0.04; I (2) = 45 %). The findings showed that LERV was associated with less clinical pancreatitis (2.4 %) than the two-stage technique (8.4 %) (OR, 0.33; 95 % CI, 0.12-0.91; P = 0.03; I (2) = 33 %). CONCLUSIONS Despite the limitation of a small number of studies completed, the evidence of RCTs shows that LERV is superior to two-stage treatment due to a reduction in overall complications, particularly pancreatitis.
Collapse
|
|
38
|
Donatelli G, Dhumane P, Dallemagne B, Perretta S, Mutter D, Delvaux M, Doffoel M, Gay G, Marescaux J. Intraoperative endoscopist-controlled guide wire cannulation technique sphincterotomy during laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech A 2012; 22:778-784. [PMID: 22957925 DOI: 10.1089/lap.2011.0506] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Intraoperative endoscopic sphincterotomy (IOES) is considered superior to preoperative endoscopic sphincterotomy and other treatment modalities for management of common bile duct (CBD) stones. Here we describe the method and results of our technique of IOES in the supine position during laparoscopic cholecystectomy (LC) using a guide wire cannulation (intraoperative supine endoscopic sphincterotomy by endoscopist-controlled guide wire cannulation) [ISEEG] technique). PATIENTS AND METHODS This is a retrospective analysis of the outcome for 36 patients undergoing LC with IOES (ISEEG technique) for acute biliary colic and jaundice with suspicion of choledocholithiasis. RESULTS On confirmation of CBD stones by intraoperative cholangiogram, CBD catheterization was successful in 34/36 (94.44%) patients with successful stone clearance in all of them by the ISEEG technique demonstrating 100% efficacy for stone clearance; the remaining 2 patients needed conversion to open surgery. The median time for the ISEEG technique during intraoperative sphincterotomy was 9 minutes (range, 7-23 minutes). Average hospital stay was 4.8 days (range, 2-15 days). At the 1-month follow-up, all patients were biliary symptom-free. Three of 36 patients (8.33%) had mild postoperative pancreatitis. There was no procedure-related mortality. CONCLUSIONS LC coupled with the ISEEG technique performed by an expert endoscopist is an effective single-stage minimally invasive treatment for CBD stones with good efficacy, good stone clearance rates, and low morbidity.
Collapse
Affiliation(s)
- Gianfranco Donatelli
- Research Institute Against Digestive Cancer/European Institute of TeleSurgery, Department of Gastrointestinal and Endocrinal Surgery, University of Strasbourg, 1 Place de l'Hôpital, Strasbourg, France.
| | | | | | | | | | | | | | | | | |
Collapse
|
|
39
|
Management of common bile duct stones in the laparoscopic era. Indian J Surg 2012; 74:264-9. [PMID: 23730054 DOI: 10.1007/s12262-012-0593-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Accepted: 05/15/2012] [Indexed: 12/11/2022] Open
Abstract
There is no consensus regarding the ideal management of concurrent gallbladder and common bile duct (CBD) stones. Currently the treatment protocol involves most commonly a sequential approach consisting of endoscopic sphincterotomy followed by laparoscopic cholecystectomy or a single stage laparoscopic procedure, including cholecystectomy and exploration of the CBD. For this article literature search was performed using online search engines, Google, Pubmed, the online Springer link library and the Cochrane Database Systematic Review. Review articles, prospective and retrospective studies which detailed or compared the various treatment strategies for CBD stones were selected and analyzed. This review article aims to provide an insight into the optimal management of CBD stones in different clinical scenarios. Endoscopic sphincterotomy has inherent morbidity and complications like CBD stone recurrence whereas laparoscopic CBD exploration demands considerable expertise which is available only at specialized centres. The clinical presentation of the patient, number of stones, size of CBD, available resources and technical expertise at hand are an important consideration for the ideal management in different scenarios.
Collapse
|
|
40
|
Rábago LR, Chico I, Collado D, Olivares A, Ortega A, Quintanilla E, Delgado M, Castro JL, Llorente R, Vazquez Echarri J. Single-stage treatment with intraoperative ERCP: management of patients with possible choledocholithiasis and gallbladder in situ in a non-tertiary Spanish hospital. Surg Endosc 2012; 26:1028-1034. [PMID: 22083324 DOI: 10.1007/s00464-011-1990-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Accepted: 09/19/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND The best way to reduce endoscopic retrograde cholangiopancreatography (ERCP) complications is not to perform it if it is unnecessary. Both intraoperative and postoperative ERCP rely on use of intraoperative cholangiography as a final diagnostic test for choledocholithiasis (CLD) whenever clinical data are unable to rule out CLD. Intraoperative ERCP could become a therapeutic option when a previous preoperative ERCP fails. We present our experience with intraoperative ERCP. PATIENTS AND METHODS This is a descriptive and prospective study of a cohort of 82 patients with moderate risk of CLD. They were operated on by laparoscopic cholecystectomy with intraoperative cholangiography (IOC). We performed intraoperative ERCP using the rendezvous technique. RESULTS Thirty-six out of 82 patients had an abnormal IOC study. Mean age was 58.7 years (standard deviation, SD 16.6, 25-83 years), and 60.6% were females. Ultrasound study showed that 51.4% of patients had a dilated bile duct. Magnetic resonance cholangiography (MRC) was performed on three patients (8.3%). The success rate of intraoperative ERCP was 88.2%. Three out of the 36 patients (8.8%) had ERCP complications [2 mild papillary bleeding (5.8%), 1 acute pancreatitis (2.9%)]. The rate of conversion to open surgery was 5% with a surgical complications rate of 4% [one injured duct and two surgical bleeding which required re-operation (2.5%)]. There were no mortalities. Four patients (11.1%) needed post-surgical ERCP, with a residual CLD rate of 5.6% (two patients) in the postoperative period. Mean surgical time was 181 min (SD 60, 75-345 min). Mean hospital stay was 6.2 days (SD 4.7, 2-24 days). CONCLUSIONS Intraoperative ERCP is an option to prevent performing ERCP unnecessarily on patients with moderate risk of CLD not confirmed using appropriate radiological studies. It can resolve the biliary disease in a single step with a similar success rate to standard ERCP, but with low morbidity, especially of acute pancreatitis. The residual CLD rate is also very low.
Collapse
Affiliation(s)
- L R Rábago
- Gastroenterology Department, Hospital Severo Ochoa, Leganés, Madrid, Spain.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
|
41
|
Rábago LR, Ortega A, Chico I, Collado D, Olivares A, Castro JL, Quintanilla E. Intraoperative ERCP: What role does it have in the era of laparoscopic cholecystectomy? World J Gastrointest Endosc 2011; 3:248-255. [PMID: 22195234 PMCID: PMC3244943 DOI: 10.4253/wjge.v3.i12.248] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2011] [Revised: 08/24/2011] [Accepted: 12/01/2011] [Indexed: 02/05/2023] Open
Abstract
In the treatment of patients with symptomatic cholelithiasis and choledocholithiasis (CBDS) detected during intraoperative cholangiography (IOC), or when the preoperative study of a patient at intermediate risk for CBDS cannot be completed due to the lack of imaging techniques required for confirmation, or if they are available and yield contradictory radiological and clinical results, patients can be treated using intraoperative endoscopic retrograde cholangiopancreatography (ERCP) during the laparoscopic treatment or postoperative ERCP if the IOC finds CBDS. The choice of treatment depends on the level of experience and availability of each option at each hospital. Intraoperative ERCP has the advantage of being a single-stage treatment and has a significant success rate, an easy learning curve, low morbidity involving a shorter hospital stay and lower costs than the two-stage treatments (postoperative and preoperative ERCP). Intraoperative ERCP is also a good salvage treatment when preoperative ERCP fails or when total laparoscopic management also fails.
Collapse
Affiliation(s)
- Luis R Rábago
- Luis R Rábago, Alejandro Ortega, Inmaculada Chico, David Collado, Ana Olivares, Jose Luis Castro, Elvira Quintanilla, Department of Gastroenterology, Severo Ochoa Hospital, Leganes, 28911 Madrid, Spain
| | | | | | | | | | | | | |
Collapse
|
|
42
|
Kozarek RA. The society for gastrointestinal intervention. Are we, as an organization of disparate disciplines, cooperative or competitive? Gut Liver 2010; 4 Suppl 1:S1-S8. [PMID: 21103287 PMCID: PMC2989558 DOI: 10.5009/gnl.2010.4.s1.s1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
This is the Fourth Annual Meeting of the Society for Gastrointestinal Intervention, a multi-disciplinary group of practitioners committed to a minimally invasive approach to both the diagnosis and treatment of digestive disorders. The key concepts are minimally invasive and multi-disciplinary which can be construed as practicing in parallel with occasional lines of procedural and clinical interaction or inter-disciplinary in which patients are acutely cared for by a team, with treatments tailored to the patient and not the discipline that touches the patient first. In reality, many of us exist in both worlds. Most universities and large clinics are structured in departments along traditional training lines. As such, Interventional Radiology is housed in the Radiology Department, Laparoscopic Surgery (and potentially NOTES), as a component of the General Surgery Division, and Therapeutic Endoscopy usually resides within a gastroenterology structural framework. These divisions have historically been kept separate by multiple forces: salaries and budgets usually reside in a larger division. As a group, the amount of practice devoted to GI disorders is variable (for instance, minimally invasive surgeons may approach the adrenal glands or lung lesions in some institutions and interventional radiologists often sample tissue in multiple areas outside the GI tract, and by virtue of access to the vascular tree, can stent, embolize, or TPA almost any area of the body), as well as inherent differences in our individual abilities to access organs. I have already mentioned that angiographic capabilities allow the interventional radiologist access to virtually every GI organ and those capabilities allow therapeutic options for bleeding, tumor embolization, stenting of stenotic lesions, and formation of intravascular shunts. As such, there is very limited interdisciplinary competition here although capsule endoscopy as well as double and single balloon enteroscopy have improved the endoscopist's diagnostic and potential therapeutic reach. However, many of these diagnostic triumphs for obscure or massive GI bleed are simply to tattoo lesions that require surgical removal by laparoscopic or traditional surgery. Cooperation. However, there are potential competitive areas in the treatment of GI vascular lesions also. Whereas endoscopic band ligation has supplanted EVS, splenic devascularization, and most shunting procedures for patients with esophageal varices, endoscopic techniques have had less long-term success with glue injection for gastric varices. Multiple randomized, prospective trials have suggested therapeutic primacy of TIPS with embolization of recalcitrant vessels as an option or back-up. Despite this, therapeutic endoscopists have learned valuable lesions from our IR colleagues and studies are underway using endoscopically injected coils in addition to cyanoacrylate in an attempt to improve acute and long-term bleeding control. Nor is there any major competition in the treatment of primary or metastatic liver tumors by chemoembolization, RF current, or other thermal modalities, although selected patients with single lesions or multiple lesions isolated to a single lobe may be better handled surgically if there is curative intent. Finally, there is little IR, and progressively less, surgical competition for the treatment of high-grade dysplasia or superficial malignancies in the setting of Barrett's esophagus which are adequately treated in most patients by mucosectomy, RF ablation, or cryotherapy but require direct mucosal visualization to direct this therapy. The same has proven true for many years for colorectal polyps, superficial gastric cancers, and ampullary adenomas that had historically all been treated with major surgical resections. Still, there are many patients with advanced lesions who are good operative candidates who should be approached with conventional or minimally invasive surgery with the intent of operative cure. Cooperative, not competitive. The potential for competition between disciplines comes in mundane situations and clinical settings that have historically been "owned" by a single discipline. On the one hand, placement of PEGS and PEJs, initially done endoscopically, can be done with equal facility and occasional failure, by endoscopists and interventional radiologists, reserving failed attempts for minimally invasive surgery. What resources are utilized with these three methods? Are there advantages to defining the mucosa of the gut lumen in all, or even a subset of patients? By way of contrast, acute cholecystectomy tubes in high surgical risk patients have usually been the domain of the radiologist, although I described transcystic duct gallbladder decompression endoscopically 2½ decades ago. With the advent of new devices delivered under EUS control, the gallbladder will now be readily accessible endoscopically. What does this mean both for the acutely ill patient without a window to approach their gallbladder radiologically? Will this play a bit part and a cooperative technique to expand our therapeutic armamentarium or will it become competitive therapeutically not only for IR but for minimally invasive surgeons? The same may be said for EUS's ability to inject genes, caustics, or chemo-therapeutic agents into organs adjacent to the lumen. What is the role of TNFerade injection into unresectable pancreatic cancers and the role of absolute alcohol or Taxitol to treat cystic neoplasms of the pancreas? The real issue of competition or cooperation between the disciplines comes when treating patients with unresectable and obstructing GI neoplasms, from my perspective. The latter may occur almost anywhere in the GI tract but, of course, are more commonly noted proximally (esophagus, stomach, duodenum) and distally (left colon) as well as proximal and distal biliary obstructions. Recognizing that the occasional mid-small bowel and many proximal colon lesions are better handled with an endoscopic approach because of loss of vector force and difficulty pushing a catheter through large diameter, acutely angulated lumens, all others are fair game from my perspective. To my knowledge, although there are studies demonstrating the superiority of SEMS over open or laparoscopic bypass for malignant gastric outlet obstruction insofar as return of gut function, hospitalization time, and resource utilization, there are no studies demonstrating the superiority of one discipline or another in the placement of SEMS. Nor have cost data emerged suggesting the superiority of one technique over another from a cost standpoint. Unless or until we have such studies, this suggests to me that institutional interest and expertise should play a major role in how these unfortunate patients have continuity of their GI tract re-established. The situation is a bit more complex in pancreaticobiliary malignancy. There are 2 prospective randomized trials (level 1 evidence) that suggest that patients with proximal strictures (Bismuth II-IV) in conjunction with bile duct and gallbladder cancer, respectively, may be more successfully stented percutaneously and certainly it is easier to deliver brachytherapy or PDT under protocol to these patients who have indwelling external drains. In contrast, there are no data, positive or negative, to suggest that PTBD is a preferable treatment for distal biliary malignant obstruction, and in most parts of the world, the endoscopic approach has supplanted the percutaneous one just as metal stents have replaced plastic prostheses to preclude recurrent bouts of stent dysfunction and need for additional ERCP. The question posed at the beginning of this syllabus contribution: Are we competitive or cooperative? The answer is obviously both but, hopefully, our choice of treatment should depend less on who touches the patient first and more on skill sets within an institution and what is the best treatment for this particular individual. The importance of the SGI is technical and informational cross-fertilization. If your university or clinic will not allow blurring of training barriers to put therapeutic endoscopists, minimally invasive surgeons, and interventional radiologists together as a department or institute, you can nevertheless work together as a team in the best interest of your patients.
Collapse
Affiliation(s)
- Richard A. Kozarek
- SGI President 2008-2010; Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| |
Collapse
|