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V V, S Kumar N, Khan O, Azharuddin SK. Giant Choledocholithiasis With Choledochal Cyst: A Report of a Rare Case. Cureus 2024; 16:e64306. [PMID: 39130959 PMCID: PMC11316851 DOI: 10.7759/cureus.64306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2024] [Indexed: 08/13/2024] Open
Abstract
A giant common bile duct (CBD) calculus is a rare occurrence, and the presence of a giant calculus within a choledochal cyst (CDC) is even more unusual. In this case report, we detail an instance of a giant CBD calculus measuring 7 cm x 3 cm found within a CDC, accompanied by multiple tiny calculi. Magnetic resonance cholangiopancreatography (MRCP) revealed the dilation of the bi-lobar intrahepatic biliary radical (IHBR) and the CBD. A large T2 hypointense and T1 hyperintense calculus occupied the dilated CBD and common hepatic duct (CHD), extending into the left hepatic duct (LHD) and right hepatic duct (RHD). There was a possibility of type 1c CDC with cystolithiasis, hepatolithiasis, and cholelithiasis. The patient underwent open cholecystectomy with choledochotomy, stone retrieval, excision of the CDC, and Roux-en-Y hepaticojejunostomy.
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Affiliation(s)
- Vinay V
- Gastrointestinal Surgery, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Nayana S Kumar
- General Surgery, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Ozair Khan
- General Surgery, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - S K Azharuddin
- Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
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Xie XM, Liu T, Wang GY. Associations of fatty acids with the risk of biliary tract calculus and inflammation: a Mendelian randomization study. Lipids Health Dis 2024; 23:8. [PMID: 38191483 PMCID: PMC10773125 DOI: 10.1186/s12944-023-01989-8] [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: 10/26/2023] [Accepted: 12/24/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND The presence of gallstones in both the gallbladder and bile ducts is referred to as cholelithiasis. The prevalence of cholecystolithiasis and bile duct stones differs. Observational and Mendelian randomization (MR) studies have elucidated the significant contributing role of numerous fatty acids (FAs) in the development of cholelithiasis. Despite numerous studies about cholelithiasis, evidence on the relationship between serum FA levels and cholecystolithiasis, as well as bile duct stones with or without inflammation, remains insufficient. METHODS A two-sample MR study was designed to clarify the impact of serum FA levels on various bile duct inflammatory diseases. The summary statistics of single nucleotide polymorphisms (SNPs) associated with fatty acids were obtained from the UK Biobank (UKB) and included data from 114,999 participants. The researchers obtained GWAS summary statistics for cholecystolithiasis and bile duct stones in 463,010 and 361,194 European participants, including cases with and without inflammation. No sample overlap between the exposure and outcome was verified through the "mr-lap" package. The SNPs were screened to identify instrumental variables (IVs). Cochran's Q test was applied for heterogeneity assessment. Inverse variance weighting (IVW) (fixed effects or random effects), MR-Egger regression and weighted median methods were used for MR. Multivariable MR was applied to determine the direct effect of each exposure on the outcome. A false discovery rate (FDR) was applied to adjust for multiple testing correction based on the Benjamini-Hochberg method. Finally, the FinnGen Consortium was used to validate some results. RESULTS The overall concentration of polyunsaturated fatty acids (PUFAs) in the serum was negatively associated with the risk of calculus of the gallbladder with acute cholecystitis (IVW, OR = 0.996, P = 0.038, CI 0.992-0.999; weighted median, OR = 0.995, P = 0.025, CI 0.991-0.999). The percentage of PUFAs to total monounsaturated fatty acids(MUFAs) (IVW, OR = 0.998, P = 0.045, CI 0.997-0.999) and the percentage of PUFAs to total FAs (IVW, OR = 0.997, P = 0.025, CI 0.995-0.999) had a protective role against cholecystitis. The percentage of PUFAs to total FAs had a protective role against calculus of the gallbladder without cholecystitis (IVW, OR = 0.995, P = 0.026, CI 0.990-0.999; MR Egger, OR = 0.99, P = 0.03, CI 0.982-0.998; weighted median, OR = 0.991, P = 5.41e-06, CI 0.988-0.995). Conversely, the percentage of MUFAs to total FAs increased the risk for cholecystitis (IVW, OR = 1.001, P = 0.034, CI 1.0001-1.002). However, there were no causal effects of the above exposures on the outcomes through multivariable MR and multiple testing correction. Finally, the causal effects of the above exposures on cholecystitis were validated in the FinnGen Consortium, which suggested that the percentage of PUFAs to total FAs (IVW, OR = 0.744, P = 0.021, CI 0.579-0.957) had a protective role against cholecystitis. CONCLUSION These Mendelian randomization findings suggested that more attention should be focused on people who have low serum PUFA levels, which may have a potential role in the occurrence of calculus of the gallbladder or cholecystitis rather than calculus of the bile duct without cholangitis or cholecystitis.
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Affiliation(s)
- Xing-Ming Xie
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, People's Republic of China
| | - Tao Liu
- Department of Hepatobiliary Surgery, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, Hubei, 445000, People's Republic of China
| | - Guo-Ying Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, People's Republic of China.
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Sekioka A, Ota S, Ito T, Mizukami Y, Tsuboi K, Okamura M, Lee Y, Ishida S, Shono Y, Shim Y, Adachi Y. How do magnetic resonance cholangiopancreatography findings predict conversion from laparoscopic cholecystectomy for acute cholecystitis to bailout procedures? Surgery 2023; 174:442-446. [PMID: 37349250 DOI: 10.1016/j.surg.2023.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/04/2023] [Accepted: 05/24/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Acute cholecystitis is one of the most prevalent surgical abdominal conditions. The Tokyo Guidelines describe the management of acute cholecystitis and recommend bailout procedures for "difficult" cholecystitis cases. This study aimed to identify risk factors for conversion from laparoscopic cholecystectomy to bailout procedures in patients with acute cholecystitis. METHODS This retrospective cohort study was conducted at a single center between January 2017 and December 2021. Patients who underwent laparoscopic cholecystectomy for acute cholecystitis were enrolled and classified into bailout and non-bailout groups. The patients' characteristics and perioperative data were compared between the 2 groups. RESULTS In total, 161 patients who underwent laparoscopic cholecystectomy for acute cholecystitis were reviewed. Fourteen were excluded because of a lack of preoperative magnetic resonance cholangiopancreatography; thus, 147 patients were enrolled (bailout group, 21; non-bailout group, 126). Age (74 vs 67 years old; P = .048), days from onset to surgery (3 vs 2 days; P = .02), or defect of cystic duct in magnetic resonance cholangiopancreatography (57% vs 29%; P = .02) were significantly associated with conversion to bailout procedures. In the logistic regression analysis, a defect of the cystic duct in magnetic resonance cholangiopancreatography was an independent predictor for bailout procedures (odds ratio, 2.793; P = .04). CONCLUSION In this study, defect of the cystic duct in the magnetic resonance cholangiopancreatography can predict conversion to bailout procedures. To the best of our knowledge, this is the first report to describe magnetic resonance cholangiopancreatography finding of the cystic duct as a predictor of surgical difficulty in patients with acute cholecystitis.
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Affiliation(s)
- Akinori Sekioka
- Department of Gastroenterological Surgery, Osaka Saiseikai-Noe Hospital, Japan.
| | - Shuichi Ota
- Department of Gastroenterological Surgery, Osaka Saiseikai-Noe Hospital, Japan
| | - Tetsuo Ito
- Department of Gastroenterological Surgery, Osaka Saiseikai-Noe Hospital, Japan
| | - Yo Mizukami
- Department of Gastroenterological Surgery, Osaka Saiseikai-Noe Hospital, Japan
| | - Kunihiko Tsuboi
- Department of Gastroenterological Surgery, Osaka Saiseikai-Noe Hospital, Japan
| | - Masahiko Okamura
- Department of Gastroenterological Surgery, Osaka Saiseikai-Noe Hospital, Japan
| | - Yoo Lee
- Department of Gastroenterological Surgery, Osaka Saiseikai-Noe Hospital, Japan
| | - Satoshi Ishida
- Department of Gastroenterological Surgery, Osaka Saiseikai-Noe Hospital, Japan
| | - Yoko Shono
- Department of Gastroenterological Surgery, Osaka Saiseikai-Noe Hospital, Japan
| | - Yugang Shim
- Department of Gastroenterological Surgery, Osaka Saiseikai-Noe Hospital, Japan
| | - Yukito Adachi
- Department of Gastroenterological Surgery, Osaka Saiseikai-Noe Hospital, Japan
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Costa PHP, de Sousa JHB, de Lima IT, Noronha MAN, Aranha GL, Arienzo VP, Lucas PFS, Steinman M, Tustumi F. The use of serum alkaline phosphatase as a choledocholithiasis marker to mitigate the cost of magnetic resonance cholangiography. EINSTEIN-SAO PAULO 2023; 21:eAO0204. [PMID: 37585886 PMCID: PMC10393214 DOI: 10.31744/einstein_journal/2023ao0204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 02/07/2023] [Indexed: 08/18/2023] Open
Abstract
OBJECTIVE To assess the predictive value of preoperative serum laboratory test results for identifying choledocholithiasis and reduce the use of cholangioresonance and its inherent costs. METHODS Patients aged 21-69 years who underwent preoperative cholangioresonance examination at our institute were included. Patients with a history of fluctuating jaundice or biliary pancreatitis, bile duct dilatation on ultrasonography, and elevated levels of canalicular enzymes (alkaline phosphatase >100U/L and gamma-glutamyl transferase >50U/L) underwent cholangioresonance-guided surgery. Cases of choledocholithiasis confirmed by cholangioresonance were compared with those without choledocholithiasis. Serum laboratory data were evaluated and the diagnostic capabilities of these examinations were analyzed. RESULTS A total of 104 patients were included. For detecting choledocholithiasis using alkaline phosphatase, the cut-off point was 78U/L, sensitivity was 97.6% (95%CI: 87.4-99.9), and specificity was 72.6% (95%CI: 59.8-83.1). In the binary logistic regression analysis, age (OR= 0.92; 95%CI: 0.86-0.98) and alkaline phosphatase level (OR= 1.02; 95%CI: 1.01-1.05) were selected for the final model. CONCLUSION Serum alkaline phosphatase levels may aid preoperative diagnosis of asymptomatic choledocholithiasis. After a global clinical assessment of the patient, serum laboratory findings may contribute to a reduction in cholangioresonance-related heathcare costs.
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Affiliation(s)
| | | | - Ian Torres de Lima
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | | | - Gabriel Lunardi Aranha
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Vitor Pelogi Arienzo
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | | | - Milton Steinman
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Francisco Tustumi
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
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Mattila A, Pynnönen E, Sironen A, Elomaa E, Mrena J, Jalkanen A, Nevalainen M, Helminen O. Routine preoperative MRCP in screening choledocholithiasis in acute cholecystitis compared to selective approach: a population-based study. Updates Surg 2022; 75:563-570. [PMID: 36207660 DOI: 10.1007/s13304-022-01390-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 09/22/2022] [Indexed: 11/24/2022]
Abstract
Choledocholithiasis is more common in acute cholecystitis than in elective situations. Preoperative diagnosis of choledocholithiasis is essential to facilitate adequate planning of CBD (common bile duct) stone removal, preferably performed as a single-stage procedure. The purpose of this study was to test the feasibility of routine preoperative magnetic resonance cholangiopancreatography (MRCP) in acute cholecystitis followed by consequent cholecystectomy. A total of 180 consecutive patients operated for acute cholecystitis between January 2019 and December 2019 were prospectively enrolled. Preoperative routine MRCP was performed for bile duct evaluation when feasible. The control cohort consisted of 180 consecutive patients undergoing emergency laparoscopic cholecystectomy before the study period. Intraoperative cholangiography was used routinely in both groups when technically achievable. We examined the proportion of patients recruited in preoperative MRCP, possible time delay to MRCP and surgery, and the incidence of CBD stones compared to the control cohort. Routine MRCP in acute cholecystitis was achieved in 114/180 (63%) patients compared to 42/180 (23.3%) patients of the control group. The triage time from emergency to MRCP and the operating theatre was similar in both cohorts. The percentage of patients diagnosed with choledocholithiasis in the study group was notably higher (almost 18% vs 11%), p < 0.05. After a median follow-up time of 2.5 years in the study group and almost 4 years in the control group, recurrent choledocholithiasis was not detected in either group. Routine MRCP in patients with acute cholecystitis can be implemented with a fair execution rate in a population-based setting with minor effects on hospital stay and delays but higher detection of choledocholithiasis. We observed no additional benefit compared to the selective use of MRCP. However, routine preoperative MRCP allows an advantage when considering the appropriate exploration method if choledocholithiasis is detected.
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Affiliation(s)
- Anne Mattila
- Dept. of Surgery, Hospital Nova of Central Finland, Hoitajantie 3, 40620, Jyväskylä, Finland.
| | - Emilia Pynnönen
- Dept. of Radiology, Hospital Nova of Central Finland, Jyväskylä, Finland
| | - Antti Sironen
- Dept. of Radiology, Hospital Nova of Central Finland, Jyväskylä, Finland
| | - Eeva Elomaa
- Dept. of Radiology, Hospital Nova of Central Finland, Jyväskylä, Finland
| | - Johanna Mrena
- Dept. of Surgery, Hospital Nova of Central Finland, Hoitajantie 3, 40620, Jyväskylä, Finland
| | - Aapo Jalkanen
- Dept. of Surgery, Hospital Nova of Central Finland, Hoitajantie 3, 40620, Jyväskylä, Finland
| | - Mika Nevalainen
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Olli Helminen
- Dept. of Surgery, Hospital Nova of Central Finland, Hoitajantie 3, 40620, Jyväskylä, Finland.,Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
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Improvement of the algorithm for diagnostics of postcholecystectomy syndrome taking into account functional and organic changes in the area of the large duodenal nipple. EUREKA: HEALTH SCIENCES 2022. [DOI: 10.21303/2504-5679.2022.002234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The aim. Improving the algorithm for diagnosing patients with postcholecystectomy syndrome (PCS), taking into account functional and organic changes in the major duodenal papilla (MDP).
Materials and methods. 208 patients with PCS were examined. Laparoscopic cholecystectomy (CE) was performed in 172 patients in history, open CE was performed in 36 patients. 47 patients had obstructive jaundice, 84 had signs of biliary hypertension without an increase in bilirubin, 77 had no signs of biliary hypertension and an increase in bilirubin.
The following instrumental research methods were used: abdominal organs ultrasound examination (AO USE), duodenoscopy, endoscopic retrograde cholangiopancreatography (ERCP), computed tomography (CT). In the main group, to study the morphofunctional changes in MDP, duodenoscopy with parietal impedancemetry, ultrasound of the hepatobiliary zone with a choleretic load were used.
Results. In the main group, 34 patients underwent ultrasound of the hepatobiliary zone and Vater's nipple area with a choleretic breakfast according to Boyden according to the method of Grigoriev P.Ya. in our modification, 21 patients had an expansion of the choledochus by 2 mm. At the same time, taking meverin led to a decrease in the diameter of the choledochus, which indicated functional changes in the MDP. In 13 patients, the expansion of the choledochus, observed when taking a choleretic breakfast, persisted with the use of antispasmodics, which indicated the presence of an organic pathology of MDP. Duodenoscopy with impedancemetry was performed in 41 patients: 20 patients had 760–820 Ohm, which indicated the presence of functional changes, 12 patients had inflammatory changes in the MDP and 703–760 Ohm were detected, 9 patients with cicatricial fibrous changes had indicators impedance measurement 640–703 Ohm. The use of ultrasound with a choleretic breakfast and duodenoscopy with parietal impedancemetry in patients of the main group made it possible to identify functional and organic (inflammatory, fibrous) changes in the MDP, which made it possible to develop a therapeutic algorithm using both conservative therapy and the use of various options for transpapillary endoscopic interventions.
Conclusions. Conducting an in-depth diagnosis of morpho-functional changes in MDP using parietal impedancemetry of MDP and ultrasound of the hepatobiliary zone with choleretic load allows us to identify both functional and morphological changes in MDP, which makes it possible to develop a therapeutic algorithm using drug therapy and transpapillary endoscopic techniques.
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Yahya S, Alabousi A, Abdullah P, Ramonas M. The Diagnostic Yield of Magnetic Resonance Cholangiopancreatography in the Setting of Acute Pancreaticobiliary Disease - A Single Center Experience. Can Assoc Radiol J 2021; 73:75-83. [PMID: 34024155 DOI: 10.1177/08465371211013786] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To discern whether preceding ultrasound (US) results, patient demographics and biochemical markers can be implemented as predictors of an abnormal Magnetic Resonance Cholangiopancreatography (MRCP) study in the context of acute pancreaticobiliary disease. METHODS A retrospective study was performed assessing US results, age, gender, elevated lipase and biliary enzymes for consecutive patients who underwent an urgent MRCP following an initial US for acute pancreaticobiliary disease between January 2017-December 2018. Multivariable binary logistic regression models were constructed to assess for predictors of clinically significant MRCPs, and discrepant US/MRCP results. RESULTS A total of 155 patients (mean age 56, 111 females) were included. Age (OR 1.03, P < 0.05), hyperlipasemia (OR 5.33, P < 0.05) and a positive US (OR 40.75, P < 0.05) were found to be independent predictors for a subsequent abnormal MRCP. Contrarily, gender and elevated biliary enzymes were not reliable predictors of an abnormal MRCP, or significant MRCP/US discrepancies. Of 66 cases (43%) of discordant US/MRCPs, half had clinically significant discrepant findings such as newly discovered choledocholithiasis and pancreaticobiliary neoplasia. Age was the sole predictor for a significant US/MRCP discrepancy, with 2% increase in the odds of a significant discrepancy per year of increase in age. CONCLUSION An abnormal US, hyperlipasemia and increased age serve as predictors for a subsequent abnormal MRCP, as opposed to gender and biliary enzyme elevation. Age was the sole predictor of a significant US/MRCP discrepancy that provided new information which significantly impacted subsequent management. In the remaining cases, however, MRCP proved useful in reaffirming the clinical diagnosis and avoiding further investigations.
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Affiliation(s)
- Sultan Yahya
- Department of Radiology, 3710McMaster University, Hamilton, Ontario, Canada.,Department of Radiology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Abdullah Alabousi
- Department of Radiology, 3710McMaster University, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Peri Abdullah
- School of Kinesiology and Health Science, 7991York University, Toronto, Ontario, Canada
| | - Milita Ramonas
- Department of Radiology, 3710McMaster University, Juravinski Hospital, Hamilton, Ontario, Canada
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One-stage versus two-stage management for acute cholecystitis associated with common bile duct stones: a retrospective cohort study. Surg Endosc 2021; 36:920-929. [PMID: 33788028 DOI: 10.1007/s00464-021-08349-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 01/27/2021] [Indexed: 12/07/2022]
Abstract
BACKGROUND Both one-stage [laparoscopic cholecystectomy (LC) plus laparoscopic common bile duct exploration (LCBDE)] and two-stage [endoscopic retrograde cholangiopancreatography (ERCP) followed by sequential LC] approaches are effective treatment for concomitant common bile duct (CBD) stones and gallstone. Although many studies compared one-stage with two-stage surgical approach for cholecysto-choledocholithiasis, there are very few studies compared the two management strategies for acute cholecystitis (AC) associated with CBD stones. METHODS Between January 2014 and December 2019, patients with concomitant AC and CBD stones proposed to early surgery were retrospectively studied. The patients were scheduled to undergo either the one-stage [LCBDE and LC (LCBDE+LC) were undertaken at the same operation] or two-stage [preoperative ERCP for CBD stone clearance was followed by LC 1-3 days later (pre-ERCP+LC)] procedure. The success rate of complete stone clearance, procedure-related complication, hospital stay, hospitalization charges and later biliary complications were compared between the two groups. RESULTS Sixty patients were included in the study, 28 in the one-stage group and 32 in the two-stage group. There was no significant difference in the success rate of complete stone clearance (96.4% vs. 93.8%, P = 1.000), complication rate (10.7% vs. 9.4%, P = 1.000), incidence of pancreatitis (0 vs. 6.3%, P = 0.494) or length of hospital stay (12 ± 5 vs. 11 ± 4 days, P = 0.393) between the two groups. CONCLUSION For patients with concomitant AC and choledocholithiasis proposed to early surgery, both the one-stage (LCBDE+LC) and two-stage (pre-ERCP+LC) approaches were acceptable and broadly comparable in achieving clearance of CBD stones.
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Preoperative Magnetic Resonance Cholangiopancreatography for Detecting Difficult Laparoscopic Cholecystectomy in Acute Cholecystitis. Diagnostics (Basel) 2021; 11:diagnostics11030383. [PMID: 33668281 PMCID: PMC7996298 DOI: 10.3390/diagnostics11030383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 02/19/2021] [Accepted: 02/20/2021] [Indexed: 12/24/2022] Open
Abstract
Previous studies have shown that signal intensity variations in the gallbladder wall on magnetic resonance imaging (MRI) are associated with necrosis and fibrosis in the gallbladder of acute cholecystitis (AC). However, the association between MRI findings and operative outcomes remains unclear. We retrospectively identified 321 patients who underwent preoperative magnetic resonance cholangiopancreatography (MRCP) and early laparoscopic cholecystectomy (LC) for AC. Based on the gallbladder wall signal intensity on MRI, these patients were divided into high signal intensity (HSI), intermediate signal intensity (ISI), and low signal intensity (LSI) groups. Comparisons of bailout procedure rates (open conversion and laparoscopic subtotal cholecystectomy) and operating times were performed. The recorded bailout procedure rates were 6.8% (7/103 cases), 26.7% (31/116 cases), and 40.2% (41/102 cases), and the median operating times were 95, 110, and 138 minutes in the HSI, ISI, and LSI groups, respectively (both p < 0.001). During the multivariate analysis, the LSI of the gallbladder wall was an independent predictor of both the bailout procedure (odds ratio [OR] 5.30; 95% CI 2.11–13.30; p < 0.001) and prolonged surgery (≥144 min) (OR 6.10, 95% CI 2.74–13.60, p < 0.001). Preoperative MRCP/MRI assessment could be a novel method for predicting surgical difficulty during LC for AC.
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Gumusoglu AY, Kabuli HA, Kones O, Karabulut M, Akbulut S, Akarsu C, Peker KD, Adas G. What is the Treatment Role of Transpapillary Cholecystostomy for Delayed Cholecystectomy in the Coexistence of Acute Cholecystitis and Cholangitis. Surg Laparosc Endosc Percutan Tech 2020; 31:71-75. [PMID: 33048896 DOI: 10.1097/sle.0000000000000851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/13/2020] [Indexed: 12/07/2022]
Abstract
INTRODUCTION This study aims to investigate the role of main bile duct drainage and gallbladder transpapillary drainage in the treatment of patients who diagnosed with acute cholecystitis and acute cholangitis because of choledocholithiasis. MATERIALS AND METHODS Patients who were admitted to the hospital with the diagnosis of acute cholecystitis between January 2018 and December 2019, have hyperbilirubinemia in their laboratory tests, and who were diagnosed with choledochal stone by magnetic resonance imaging and magnetic resonance cholangiopancreatography imaging because of the findings of cholangitis were included in this study. These patients underwent endoscopic retrograde cholangiopancreatography (ERCP) and choledochus stone extraction procedure and gallbladder drainage with the transpapillary pigtail. The demographic data, success rates, and complications of the patients were evaluated. RESULTS A total of 19 patients were included in the study. Choledochus was cannulated in all patients, but gallbladder drainage could not be achieved in 2 patients. These 2 patients were recorded under the unsuccessful method use. Although 2 patients could not be operated because of high comorbidity (American Society of Anesthesiologists IV), they underwent percutaneous cholecystostomy because of the development of cholecystitis arising from an obstruction in the pigtail catheter in the 11th and 12th weeks. Treatments of the remaining 15 patients and subsequent cholecystectomy procedures were successful. The mean age of the patients was 54.52 years. Of the patients, 9 were female and 6 were male. In the 6th week of follow-up, 15 patients underwent laparoscopic cholecystectomy with ERCP 1 day after removal of the stent and pigtail catheter. CONCLUSIONS Transpapillary cholecystectomy with ERCP is a successful method of treatment in patients with acute cholecystitis with the symptoms of cholangitis because of choledochal stone.
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Affiliation(s)
- Alpen Y Gumusoglu
- Department of General Surgery, Bakirkoy Dr. Sadi Konuk Training and Research Hospital
| | - Hamit A Kabuli
- Department of General Surgery, Bakirkoy Dr. Sadi Konuk Training and Research Hospital
| | - Osman Kones
- Department of General Surgery, Bakirkoy Dr. Sadi Konuk Training and Research Hospital
| | - Mehmet Karabulut
- Department of General Surgery, Bakirkoy Dr. Sadi Konuk Training and Research Hospital
| | - Sezer Akbulut
- Department of General Surgery, Bakirkoy Dr. Sadi Konuk Training and Research Hospital
| | - Cevher Akarsu
- Department of General Surgery, Bakirkoy Dr. Sadi Konuk Training and Research Hospital
| | - Kivanc D Peker
- Department of General Surgery, Basaksehir Cam and Sakura Training and Research Hospital, Health Science University, Istanbul, Turkey
| | - Gokhan Adas
- Department of General Surgery, Bakirkoy Dr. Sadi Konuk Training and Research Hospital
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Chen H, Jorissen R, Walcott J, Nikfarjam M. Incidence and predictors of common bile duct stones in patients with acute cholecystitis: a systematic literature review and meta‐analysis. ANZ J Surg 2019; 90:1598-1603. [DOI: 10.1111/ans.15565] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 09/16/2019] [Accepted: 09/18/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Hongyi Chen
- Department of Surgery The University of Melbourne, Austin Health Melbourne Victoria Australia
| | - Robert Jorissen
- Systems Biology and Personalised Medicine Division Walter and Eliza Hall Institute of Medical Research Melbourne Victoria Australia
| | - James Walcott
- Department of Surgery The University of Melbourne, Austin Health Melbourne Victoria Australia
| | - Mehrdad Nikfarjam
- Department of Surgery The University of Melbourne, Austin Health Melbourne Victoria Australia
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Bilirubin Correlation May Preclude MRCP in Acute Cholecystitis Patients With Normal Common Bile Duct Diameter. AJR Am J Roentgenol 2019; 212:1018-1023. [PMID: 30860886 DOI: 10.2214/ajr.18.20613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE. In patients with acute cholecystitis (AC), accurate identification of a common bile duct (CBD) stone before cholecystectomy is of concern for surgeons, gastroenterologists, and radiologists. This study evaluates the utility of preoperative MRCP taking into consideration both sonographic findings and biochemical predictors for choledocholithiasis. MATERIALS AND METHODS. Fifty-seven patients (58% women; mean age, 54 years old) with signs of AC on right upper quadrant (RUQ) ultrasound (US) who underwent subsequent MRCP from 2007 to 2017 were identified using a text-based search and retrospectively analyzed, using ERCP as the reference standard. RESULTS. For patients with AC who had a normal CBD diameter on initial RUQ US, we found a significant difference in the total and direct bilirubin levels of patients who had positive (1.94 vs 4.02 mg/dL, respectively; p = 0.013) and negative (0.71 vs 2.13 mg/dL, respectively; p = 0.02) findings for CBD stone on MRCP. ROC curve analysis showed an increased total bilirubin threshold of > 2.3 mg/dL (standard threshold, 1.2 mg/dL), which yielded a negative predictive value (NPV) of 95%. An increased direct bilirubin threshold of > 0.9 mg/dL (standard threshold, 0.2 mg/dL) yielded an NPV of 100%. CONCLUSION. In patients with AC who have a normal CBD diameter on RUQ US, normal or even mildly elevated bilirubin levels below a calculated threshold may obviate preoperative MRCP. Radiologists should be active participants in clinical decision-making; discussion between referring physicians and radiologists regarding biochemical markers and sonographic findings will lead to more appropriate use of preoperative imaging.
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Leal CA, Ortega DJ, Pedraza M, Cabrera LF, Sánchez S. Eficacia de la colangiopancreatografía por resonancia magnética para el diagnóstico de coledocolitiasis de probabilidad intermedia. REVISTA COLOMBIANA DE CIRUGÍA 2019. [DOI: 10.30944/20117582.96] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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14
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Wakabayashi G, Iwashita Y, Hibi T, Takada T, Strasberg SM, Asbun HJ, Endo I, Umezawa A, Asai K, Suzuki K, Mori Y, Okamoto K, Pitt HA, Han HS, Hwang TL, Yoon YS, Yoon DS, Choi IS, Huang WSW, Giménez ME, Garden OJ, Gouma DJ, Belli G, Dervenis C, Jagannath P, Chan ACW, Lau WY, Liu KH, Su CH, Misawa T, Nakamura M, Horiguchi A, Tagaya N, Fujioka S, Higuchi R, Shikata S, Noguchi Y, Ukai T, Yokoe M, Cherqui D, Honda G, Sugioka A, de Santibañes E, Supe AN, Tokumura H, Kimura T, Yoshida M, Mayumi T, Kitano S, Inomata M, Hirata K, Sumiyama Y, Inui K, Yamamoto M. Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos). JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2018; 25:73-86. [PMID: 29095575 DOI: 10.1002/jhbp.517] [Citation(s) in RCA: 280] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In some cases, laparoscopic cholecystectomy (LC) may be difficult to perform in patients with acute cholecystitis (AC) with severe inflammation and fibrosis. The Tokyo Guidelines 2018 (TG18) expand the indications for LC under difficult conditions for each level of severity of AC. As a result of expanding the indications for LC to treat AC, it is absolutely necessary to avoid any increase in bile duct injury (BDI), particularly vasculo-biliary injury (VBI), which is known to occur at a certain rate in LC. Since the Tokyo Guidelines 2013 (TG13), an attempt has been made to assess intraoperative findings as objective indicators of surgical difficulty; based on expert consensus on these difficulty indicators, bail-out procedures (including conversion to open cholecystectomy) have been indicated for cases in which LC for AC is difficult to perform. A bail-out procedure should be chosen if, when the Calot's triangle is appropriately retracted and used as a landmark, a critical view of safety (CVS) cannot be achieved because of the presence of nondissectable scarring or severe fibrosis. We propose standardized safe steps for LC to treat AC. To achieve a CVS, it is vital to dissect at a location above (on the ventral side of) the imaginary line connecting the base of the left medial section (Segment 4) and the roof of Rouvière's sulcus and to fulfill the three criteria of CVS before dividing any structures. Achieving a CVS prevents the misidentification of the cystic duct and the common bile duct, which are most commonly confused. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.
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Affiliation(s)
- Go Wakabayashi
- Department of Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Yukio Iwashita
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Taizo Hibi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Tadahiro Takada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Steven M Strasberg
- Section of Hepato-Pancreato-Biliary Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Horacio J Asbun
- Department of Surgery, Mayo Clinic College of Medicine, Jacksonville, FL, USA
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
| | - Akiko Umezawa
- Minimally Invasive Surgery Center, Yotsuya Medical Cube, Tokyo, Japan
| | - Koji Asai
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Kenji Suzuki
- Department of Surgery, Fujinomiya City General Hospital, Shizuoka, Japan
| | - Yasuhisa Mori
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Fukuoka, Japan
| | - Henry A Pitt
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Tsann-Long Hwang
- Division of General Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Dong-Sup Yoon
- Department of Surgery, Yonsei University Gangnam Severance Hospital, Seoul, Korea
| | - In-Seok Choi
- Department of Surgery, Konyang University Hospital, Daejeon, Korea
| | | | - Mariano Eduardo Giménez
- Chair of General Surgery and Minimal Invasive Surgery "Taquini" University of Buenos Aires, DAICIM Foundation, Buenos Aires, Argentina
| | - O James Garden
- Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Dirk J Gouma
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Giulio Belli
- Department of General and HPB Surgery, Loreto Nuovo Hospital, Naples, Italy
| | | | - Palepu Jagannath
- Department of Surgical Oncology, Lilavati Hospital and Research Centre, Mumbai, India
| | - Angus C W Chan
- Department of Surgery, Surgery Centre, Hong Kong Sanatorium and Hospital, Hong Kong
| | - Wan Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Keng-Hao Liu
- Division of General Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Cheng-Hsi Su
- Department of Surgery, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Takeyuki Misawa
- Department of Surgery, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akihiko Horiguchi
- Department of Gastroenterological Surgery, Fujita Health University School of Medicine, Aichi, Japan
| | - Nobumi Tagaya
- Department of Surgery, Dokkyo Medical University Koshigaya Hospital, Saitma, Japan
| | - Shuichi Fujioka
- Department of Surgery, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | | | - Yoshinori Noguchi
- Department of General Internal Medicine, Japanese Red Cross Nagoya Daini Hospital, Aichi, Japan
| | - Tomohiko Ukai
- Department of Family Medicine, Mie Prefectural Ichishi Hospital, Mie, Japan
| | - Masamichi Yokoe
- Department of General Internal Medicine, Japanese Red Cross Nagoya Daini Hospital, Aichi, Japan
| | - Daniel Cherqui
- Hepatobiliary Center, Paul Brousse Hospital, Villejuif, France
| | - Goro Honda
- Department of Surgery, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Atsushi Sugioka
- Department of Surgery, Fujita Health University School of Medicine, Aichi, Japan
| | - Eduardo de Santibañes
- Department of Surgery, Hospital Italiano, University of Buenos Aires, Buenos Aires, Argentina
| | - Avinash Nivritti Supe
- Department of Surgical Gastroenterology, Seth G S Medical College and K E M Hospital, Mumbai, India
| | | | - Taizo Kimura
- Department of Surgery, Fujinomiya City General Hospital, Shizuoka, Japan
| | - Masahiro Yoshida
- Department of Hemodialysis and Surgery, Ichikawa Hospital, International University of Health and Welfare, Chiba, Japan.,Department of EBM and Guidelines, Japan Council for Quality Health Care, Tokyo, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine University of Occupational and Environmental Health, Fukuoka, Japan
| | | | - Masafumi Inomata
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Koichi Hirata
- Department of Surgery, JR Sapporo Hospital, Hokkaido, Japan
| | | | - Kazuo Inui
- Department of Gastroenterology, Second Teaching Hospital, Fujita Health University, Aichi, Japan
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Gouveia C, Loureiro R, Ferreira R, Oliveira Ferreira A, Santos AA, Santos MPC, Palmela C, Cravo M. Performance of the Choledocholithiasis Diagnostic Score in Patients with Acute Cholecystitis. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2017; 25:24-29. [PMID: 29457047 DOI: 10.1159/000479973] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 07/04/2017] [Indexed: 01/27/2023]
Abstract
Introduction The prevalence of choledocholithiasis among patients with acute cholecystitis is estimated to be between 9 and 16.5%. There are no validated algorithms to predict choledocholithiasis in this group of patients. Aim The aim of this study was to evaluate the performance of the choledocholithiasis diagnostic score proposed by the American Society for Gastrointestinal Endoscopy, in patients with acute cholecystitis. Material/Methods A retrospective cross-sectional study, covering a 4-year period at a secondary care hospital, was performed. All patients with an encoded diagnosis of acute cholecystitis and with at least one of the following procedures were included: endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound, magnetic resonance cholangiopancreatography, and intraoperative cholangiography. Results Among 4,369 patients with the diagnosis of acute cholecystitis, 40 (0.92%) had clinical or sonographic suspicion of choledocholithiasis. Their mean age was 68.1 ± 15 years, and 22 (55%) were men. Thirty-one of the patients included (77.5%) had a high risk of choledocholithiasis, and 9 (22.5%) had an intermediate risk. In 16 (51.6%) of the 31 patients with a high risk, the diagnosis of choledocholithiasis was confirmed. In 2 (22.2%) of the 9 patients with an intermediate risk, the diagnosis of choledocholithiasis was also confirmed. The high risk score for choledocholithiasis had a positive predictive value of 52% and a sensitivity of 89%. The intermediate risk score for choledocholithiasis had a positive predictive value of 22% and a sensitivity of 11%. Discussion and Conclusions Suspicion of choledocholithiasis in patients with acute cholecystitis was a rare event (<1%). The sensitivity of the high risk score was approximately the same as found in published series with patients with suspected choledocholithiasis overall (86%), while the positive predictive value was substantially lower (52 vs. 79.8%). Therefore, in patients with acute cholecystitis and suspected choledocholithiasis, this score should not be used to screen for common bile duct stones, and a sensitive method should be used prior to ERCP.
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Affiliation(s)
- Catarina Gouveia
- Serviço de Gastrenterologia, Hospital Beatriz Ângelo, Lisbon, Portugal
| | - Rui Loureiro
- Serviço de Gastrenterologia, Hospital Beatriz Ângelo, Lisbon, Portugal
| | - Rosa Ferreira
- Serviço de Gastrenterologia, Hospital Beatriz Ângelo, Lisbon, Portugal
| | | | | | | | - Carolina Palmela
- Serviço de Gastrenterologia, Hospital Beatriz Ângelo, Lisbon, Portugal
| | - Marília Cravo
- Serviço de Gastrenterologia, Hospital Beatriz Ângelo, Lisbon, Portugal
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Hjartarson JH, Hannesson P, Sverrisson I, Blöndal S, Ívarsson B, Björnsson ES. The value of magnetic resonance cholangiopancreatography for the exclusion of choledocholithiasis. Scand J Gastroenterol 2016; 51:1249-56. [PMID: 27181286 DOI: 10.1080/00365521.2016.1182584] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To investigate the ability of Magnetic resonance cholangiopancreatography (MRCP) to exclude choledocholithiasis (CDL) in symptomatic patients. MATERIAL AND METHODS Patients suspected of choledocholithiasis who underwent MRCP from 2008 through 2013 in a population based study at the National University Hospital of Iceland were retrospectively analysed, using ERCP and/or intraoperative cholangiography as a gold standard diagnosis for CDL. RESULTS Overall 920 patients [66% women, mean age 55 years (SD 21)] underwent MRCP. A total of 392 patients had a normal MRCP of which 71 underwent an ERCP investigation demonstrating a CBD stone in 29 patients. A normal MRCP was found to have a 93% negative predictive value (NPV) and 89% probability of having no CBD stone demonstrated as well as no readmission due to gallstone disease within six months following MRCP. During a 6-month follow-up period of the 321 patients who did not undergo an ERCP nine (2.8%) patients were readmitted with right upper quadrant pain and elevated liver tests which later normalised with no CBD stone being demonstrated, three (0.9%) patients were readmitted with presumed gallstone pancreatitis, two (0.6%) patients were readmitted with cholecystitis and two (0.6%) patients were lost to follow-up. Seven patients of those 321 underwent an intraoperative cholangiography (IOC) and all were negative for CBD stones. For the sub-group requiring ERCP following a normal MRCP the NPV was 63%. CONCLUSION Our results support the use of MRCP as a tool for exclusion of choledocholithiasis with the potential to reduce the amount of unnecessary ERCP procedures.
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Affiliation(s)
- Jón H Hjartarson
- a Department of Gastroenterology and Hepatology , The National University Hospital of Iceland , Reykjavík , Iceland
| | - Pétur Hannesson
- b Department of Radiology , The National University Hospital of Iceland , Reykjavík , Iceland
| | - Ingvar Sverrisson
- c Department of Surgery , The National University Hospital of Iceland , Reykjavík , Iceland
| | - Sigurður Blöndal
- c Department of Surgery , The National University Hospital of Iceland , Reykjavík , Iceland
| | - Bjarki Ívarsson
- b Department of Radiology , The National University Hospital of Iceland , Reykjavík , Iceland
| | - Einar S Björnsson
- a Department of Gastroenterology and Hepatology , The National University Hospital of Iceland , Reykjavík , Iceland
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17
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Chandarana H, Doshi AM, Shanbhogue A, Babb JS, Bruno MT, Zhao T, Raithel E, Zenge MO, Li G, Otazo R. Three-dimensional MR Cholangiopancreatography in a Breath Hold with Sparsity-based Reconstruction of Highly Undersampled Data. Radiology 2016; 280:585-94. [PMID: 26982678 DOI: 10.1148/radiol.2016151935] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To develop a three-dimensional breath-hold (BH) magnetic resonance (MR) cholangiopancreatographic protocol with sampling perfection with application-optimized contrast using different flip-angle evolutions (SPACE) acquisition and sparsity-based iterative reconstruction (SPARSE) of prospectively sampled 5% k-space data and to compare the results with conventional respiratory-triggered (RT) acquisition. Materials and Methods This HIPAA-compliant prospective study was institutional review board approved. Twenty-nine patients underwent conventional RT SPACE and BH-accelerated SPACE acquisition with 5% k-space sampling at 3 T. Spatial resolution and other parameters were matched when possible. BH SPACE images were reconstructed by enforcing joint multicoil sparsity in the wavelet domain (SPARSE-SPACE). Two board-certified radiologists independently evaluated BH SPARSE-SPACE and RT SPACE images for image quality parameters in the pancreatic duct and common bile duct by using a five-point scale. The Wilcoxon signed-rank test was used to compare BH SPARSE-SPACE and RT SPACE images. Results Acquisition time for BH SPARSE-SPACE was 20 seconds, which was significantly (P < .001) shorter than that for RT SPACE (mean ± standard deviation, 338.8 sec ± 69.1). Overall image quality scores were higher for BH SPARSE-SPACE than for RT SPACE images for both readers for the proximal, middle, and distal pancreatic duct, but the difference was not statistically significant (P > .05). For reader 1, distal common bile duct scores were significantly higher with BH SPARSE-SPACE acquisition (P = .036). More patients had acceptable or better overall image quality (scores ≥ 3) with BH SPARSE-SPACE than with RT SPACE acquisition, respectively, for the proximal (23 of 29 [79%] vs 22 of 29 [76%]), middle (22 of 29 [76%] vs 18 of 29 [62%]), and distal (20 of 29 [69%] vs 13 of 29 [45%]) pancreatic duct and the proximal (25 of 28 [89%] vs 22 of 28 [79%]) and distal (25 of 28 [89%] vs 24 of 28 [86%]) common bile duct. Conclusion BH SPARSE-SPACE showed similar or superior image quality for the pancreatic and common duct compared with that of RT SPACE despite 17-fold shorter acquisition time. (©) RSNA, 2016.
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Affiliation(s)
- Hersh Chandarana
- From the Center for Advanced Imaging Innovation and Research (CAI2R) (H.C., J.S.B., R.O.) and Bernard and Irene Schwartz Center for Biomedical Imaging (H.C., A.M.D., A.S., J.S.B., M.T.B., R.O.), Department of Radiology, New York University School of Medicine, 660 First Ave, New York, NY 10016; Siemens Healthcare, New York, NY (T.Z., M.O.Z.); Siemens Healthcare, Erlangen, Germany (E.R.); and Department of Radiology, Section of Medical Physics, Freiburg University Medical Center, Freiburg, Germany (G.L.)
| | - Ankur M Doshi
- From the Center for Advanced Imaging Innovation and Research (CAI2R) (H.C., J.S.B., R.O.) and Bernard and Irene Schwartz Center for Biomedical Imaging (H.C., A.M.D., A.S., J.S.B., M.T.B., R.O.), Department of Radiology, New York University School of Medicine, 660 First Ave, New York, NY 10016; Siemens Healthcare, New York, NY (T.Z., M.O.Z.); Siemens Healthcare, Erlangen, Germany (E.R.); and Department of Radiology, Section of Medical Physics, Freiburg University Medical Center, Freiburg, Germany (G.L.)
| | - Alampady Shanbhogue
- From the Center for Advanced Imaging Innovation and Research (CAI2R) (H.C., J.S.B., R.O.) and Bernard and Irene Schwartz Center for Biomedical Imaging (H.C., A.M.D., A.S., J.S.B., M.T.B., R.O.), Department of Radiology, New York University School of Medicine, 660 First Ave, New York, NY 10016; Siemens Healthcare, New York, NY (T.Z., M.O.Z.); Siemens Healthcare, Erlangen, Germany (E.R.); and Department of Radiology, Section of Medical Physics, Freiburg University Medical Center, Freiburg, Germany (G.L.)
| | - James S Babb
- From the Center for Advanced Imaging Innovation and Research (CAI2R) (H.C., J.S.B., R.O.) and Bernard and Irene Schwartz Center for Biomedical Imaging (H.C., A.M.D., A.S., J.S.B., M.T.B., R.O.), Department of Radiology, New York University School of Medicine, 660 First Ave, New York, NY 10016; Siemens Healthcare, New York, NY (T.Z., M.O.Z.); Siemens Healthcare, Erlangen, Germany (E.R.); and Department of Radiology, Section of Medical Physics, Freiburg University Medical Center, Freiburg, Germany (G.L.)
| | - Mary T Bruno
- From the Center for Advanced Imaging Innovation and Research (CAI2R) (H.C., J.S.B., R.O.) and Bernard and Irene Schwartz Center for Biomedical Imaging (H.C., A.M.D., A.S., J.S.B., M.T.B., R.O.), Department of Radiology, New York University School of Medicine, 660 First Ave, New York, NY 10016; Siemens Healthcare, New York, NY (T.Z., M.O.Z.); Siemens Healthcare, Erlangen, Germany (E.R.); and Department of Radiology, Section of Medical Physics, Freiburg University Medical Center, Freiburg, Germany (G.L.)
| | - Tiejun Zhao
- From the Center for Advanced Imaging Innovation and Research (CAI2R) (H.C., J.S.B., R.O.) and Bernard and Irene Schwartz Center for Biomedical Imaging (H.C., A.M.D., A.S., J.S.B., M.T.B., R.O.), Department of Radiology, New York University School of Medicine, 660 First Ave, New York, NY 10016; Siemens Healthcare, New York, NY (T.Z., M.O.Z.); Siemens Healthcare, Erlangen, Germany (E.R.); and Department of Radiology, Section of Medical Physics, Freiburg University Medical Center, Freiburg, Germany (G.L.)
| | - Esther Raithel
- From the Center for Advanced Imaging Innovation and Research (CAI2R) (H.C., J.S.B., R.O.) and Bernard and Irene Schwartz Center for Biomedical Imaging (H.C., A.M.D., A.S., J.S.B., M.T.B., R.O.), Department of Radiology, New York University School of Medicine, 660 First Ave, New York, NY 10016; Siemens Healthcare, New York, NY (T.Z., M.O.Z.); Siemens Healthcare, Erlangen, Germany (E.R.); and Department of Radiology, Section of Medical Physics, Freiburg University Medical Center, Freiburg, Germany (G.L.)
| | - Michael O Zenge
- From the Center for Advanced Imaging Innovation and Research (CAI2R) (H.C., J.S.B., R.O.) and Bernard and Irene Schwartz Center for Biomedical Imaging (H.C., A.M.D., A.S., J.S.B., M.T.B., R.O.), Department of Radiology, New York University School of Medicine, 660 First Ave, New York, NY 10016; Siemens Healthcare, New York, NY (T.Z., M.O.Z.); Siemens Healthcare, Erlangen, Germany (E.R.); and Department of Radiology, Section of Medical Physics, Freiburg University Medical Center, Freiburg, Germany (G.L.)
| | - Guobin Li
- From the Center for Advanced Imaging Innovation and Research (CAI2R) (H.C., J.S.B., R.O.) and Bernard and Irene Schwartz Center for Biomedical Imaging (H.C., A.M.D., A.S., J.S.B., M.T.B., R.O.), Department of Radiology, New York University School of Medicine, 660 First Ave, New York, NY 10016; Siemens Healthcare, New York, NY (T.Z., M.O.Z.); Siemens Healthcare, Erlangen, Germany (E.R.); and Department of Radiology, Section of Medical Physics, Freiburg University Medical Center, Freiburg, Germany (G.L.)
| | - Ricardo Otazo
- From the Center for Advanced Imaging Innovation and Research (CAI2R) (H.C., J.S.B., R.O.) and Bernard and Irene Schwartz Center for Biomedical Imaging (H.C., A.M.D., A.S., J.S.B., M.T.B., R.O.), Department of Radiology, New York University School of Medicine, 660 First Ave, New York, NY 10016; Siemens Healthcare, New York, NY (T.Z., M.O.Z.); Siemens Healthcare, Erlangen, Germany (E.R.); and Department of Radiology, Section of Medical Physics, Freiburg University Medical Center, Freiburg, Germany (G.L.)
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Qiu Y, Yang Z, Li Z, Zhang W, Xue D. Is preoperative MRCP necessary for patients with gallstones? An analysis of the factors related to missed diagnosis of choledocholithiasis by preoperative ultrasound. BMC Gastroenterol 2015; 15:158. [PMID: 26577949 PMCID: PMC4650402 DOI: 10.1186/s12876-015-0392-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 11/10/2015] [Indexed: 02/07/2023] Open
Abstract
Background The diagnosis of associated choledocholithiasis prior to cholecystectomy for patients with gallstones is important for the surgical decision and treatment efficacy. However, whether ultrasound is sufficient for preoperative diagnosis of choledocholithiasis remains controversial, with different opinions on whether routine magnetic resonance cholangiopancreatography (MRCP) is needed to detect the possible presence of common bile duct (CBD) stones. Methods In this study, a total of 413 patients with gallstones who were admitted to the Department of General Surgery of the First Affiliated Hospital of Harbin Medical University in China for a period of 3 years and underwent both ultrasound and MRCP examinations were retrospectively analysed. After reviewing and screening these cases according to the literature, 11 indicators including gender, age, alanine aminotransferase, aspartate aminotransferase, total bilirubin, direct bilirubin, indirect bilirubin, alkaline phosphatase, γ-aminotransferase, CBD diameter, and concurrent acute cholecystitis were selected and comparatively analysed. Results Among the 413 patients, a total of 109 cases showed concurrent gallstones and choledocholithiasis, accounting for 26.39 % of all cases. Among them, 60 cases of choledocholithiasis were revealed by ultrasound examination, accounting for 55.05 %, while 49 cases of choledocholithiasis were not detected by ultrasound examination but were confirmed by MRCP instead (the missed diagnosis rate of ultrasound was 44.95 %). The results of statistical analysis suggested that alanine aminotransferase, acute cholecystitis, and CBD diameter were the three most relevant factors for missed diagnosis by ultrasound. Conclusion The accuracy of preoperative ultrasonography for the diagnosis of associated CBD stones for patients with gallstones is not high. However, elevated alanine aminotransferase, concurrent acute cholecystitis, and CBD diameter were identified as key factors that may affect the accuracy of the diagnosis. Thus, routine preoperative MRCP examination is suggested for patients with gallstones to rule out possible concomitant CBD stones.
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Affiliation(s)
- Yan Qiu
- Department of General Surgery, the First Affiliated Hospital of Harbin Medical University, 23 Youzheng St., Nangang Dist., 150001, Harbin, China.
| | - Zhengpeng Yang
- Department of General Surgery, the First Affiliated Hospital of Harbin Medical University, 23 Youzheng St., Nangang Dist., 150001, Harbin, China.
| | - Zhituo Li
- Department of General Surgery, the First Affiliated Hospital of Harbin Medical University, 23 Youzheng St., Nangang Dist., 150001, Harbin, China.
| | - Weihui Zhang
- Department of General Surgery, the First Affiliated Hospital of Harbin Medical University, 23 Youzheng St., Nangang Dist., 150001, Harbin, China.
| | - Dongbo Xue
- Department of General Surgery, the First Affiliated Hospital of Harbin Medical University, 23 Youzheng St., Nangang Dist., 150001, Harbin, China.
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19
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Early versus delayed same-admission laparoscopic cholecystectomy for acute cholecystitis in elderly patients with comorbidities. J Trauma Acute Care Surg 2015; 78:801-7. [PMID: 25742252 DOI: 10.1097/ta.0000000000000577] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The optimal timing of same-admission laparoscopic cholecystectomy (LC) for acute cholecystitis (AC) in elderly patients, especially those with significant comorbidities, is not clear. METHODS This is a National Surgical Quality Improvement Program study, which included patients older than 65 years undergoing LC for AC. Patients with choledocholithiasis were excluded. Patients were divided into two subgroups as follows: no significant comorbidities (American Society of Anesthesiologists [ASA] score ≤ 2) and significant comorbidities (ASA score > 2). Patients undergoing LC within 24 hours of admission (early LC) were compared with patients undergoing LC later than 24 hours after admission (delayed LC), using univariable and multivariable regression analyses. RESULTS A total of 4,011 patients were included in the study. Early LC was performed in 38.0% and delayed LC in 62.0% of the patients. Regression analysis identified early LC as an independent predictor for shorter anesthesia time and postoperative length of stay, overall and in the subgroup with an ASA score greater than 2. CONCLUSION Early, within 24 hours of admission, LC for AC in patients older than 65 years with significant comorbidities is associated with shorter postoperative stay and no increase in postoperative complications or conversion to open cholecystectomy. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Chen W, Mo JJ, Lin L, Li CQ, Zhang JF. Diagnostic value of magnetic resonance cholangiopancreatography in choledocholithiasis. World J Gastroenterol 2015; 21:3351-3360. [PMID: 25805944 PMCID: PMC4363767 DOI: 10.3748/wjg.v21.i11.3351] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Revised: 08/26/2014] [Accepted: 10/15/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) in patients with choledocholithiasis.
METHODS: We systematically searched MEDLINE, EMBASE, Web of Science, and Cochrane databases for studies reporting on the sensitivity, specificity and other accuracy measures of diagnostic effectiveness of MRCP for detection of common bile duct (CBD) stones. Pooled analysis was performed using random effects models, and receiver operating characteristic curves were generated to summarize overall test performance. Two reviewers independently assessed the methodological quality of studies using standards for reporting diagnostic accuracy and quality assessment for studies of diagnostic accuracy tools.
RESULTS: A total of 25 studies involving 2310 patients with suspected choledocholithiasis and 738 patients with CBD stones met the inclusion criteria. The average inter-rater agreement on the methodological quality checklists was 0.96. Pooled analysis of the ability of MRCP to detect CBD stones showed the following effect estimates: sensitivity, 0.90 (95%CI: 0.88-0.92, χ2 = 65.80; P < 0.001); specificity, 0.95 (95%CI: 0.93-1.0, χ2 = 110.51; P < 0.001); positive likelihood ratio, 13.28 (95%CI: 8.85-19.94, χ2 = 78.95; P < 0.001); negative likelihood ratio, 0.13 (95%CI: 0.09-0.18, χ2 = 6.27; P < 0.001); and diagnostic odds ratio, 143.82 (95%CI: 82.42-250.95, χ2 = 44.19; P < 0.001). The area under the receiver operating characteristic curve was 0.97. Significant publication bias was not detected (P = 0.266).
CONCLUSION: MRCP has high diagnostic accuracy for the detection of choledocholithiasis. MRCP should be the method of choice for suspected cases of CBD stones.
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Giljaca V, Gurusamy KS, Takwoingi Y, Higgie D, Poropat G, Štimac D, Davidson BR. Endoscopic ultrasound versus magnetic resonance cholangiopancreatography for common bile duct stones. Cochrane Database Syst Rev 2015; 2015:CD011549. [PMID: 25719224 PMCID: PMC6464848 DOI: 10.1002/14651858.cd011549] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) are tests used in the diagnosis of common bile duct stones in patients suspected of having common bile duct stones prior to undergoing invasive treatment. There has been no systematic review of the accuracy of EUS and MRCP in the diagnosis of common bile duct stones using appropriate reference standards. OBJECTIVES To determine and compare the accuracy of EUS and MRCP for the diagnosis of common bile duct stones. SEARCH METHODS We searched MEDLINE, EMBASE, Science Citation Index Expanded, BIOSIS, and Clinicaltrials.gov until September 2012. We searched the references of included studies to identify further studies and of systematic reviews identified from various databases (Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment (HTA), Medion, and ARIF (Aggressive Research Intelligence Facility)). We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively. SELECTION CRITERIA We included studies that provided the number of true positives, false positives, false negatives, and true negatives for EUS or MRCP. We only accepted studies that confirmed the presence of common bile duct stones by extraction of the stones (irrespective of whether this was done by surgical or endoscopic methods) for a positive test, and absence of common bile duct stones by surgical or endoscopic negative exploration of the common bile duct or symptom free follow-up for at least six months for a negative test, as the reference standard in people suspected of having common bile duct stones. We included participants with or without prior diagnosis of cholelithiasis; with or without symptoms and complications of common bile duct stones, with or without prior treatment for common bile duct stones; and before or after cholecystectomy. At least two authors independently screened abstracts and selected studies for inclusion. DATA COLLECTION AND ANALYSIS Two authors independently collected the data from each study. We used the bivariate model to obtain pooled estimates of sensitivity and specificity. MAIN RESULTS We included a total of 18 studies involving 2366 participants (976 participants with common bile duct stones and 1390 participants without common bile duct stones). Eleven studies evaluated EUS alone, and five studies evaluated MRCP alone. Two studies evaluated both tests. Most studies included patients who were suspected of having common bile duct stones based on abnormal liver function tests; abnormal transabdominal ultrasound; symptoms such as obstructive jaundice, cholangitis, or pancreatitis; or a combination of the above. The proportion of participants who had undergone cholecystectomy varied across studies. Not one of the studies was of high methodological quality. For EUS, the sensitivities ranged between 0.75 and 1.00 and the specificities ranged between 0.85 and 1.00. The summary sensitivity (95% confidence interval (CI)) and specificity (95% CI) of the 13 studies that evaluated EUS (1537 participants; 686 cases and 851 participants without common bile duct stones) were 0.95 (95% CI 0.91 to 0.97) and 0.97 (95% CI 0.94 to 0.99). For MRCP, the sensitivities ranged between 0.77 and 1.00 and the specificities ranged between 0.73 and 0.99. The summary sensitivity and specificity of the seven studies that evaluated MRCP (996 participants; 361 cases and 635 participants without common bile duct stones) were 0.93 (95% CI 0.87 to 0.96) and 0.96 (95% CI 0.90 to 0.98). There was no evidence of a difference in sensitivity or specificity between EUS and MRCP (P value = 0.5). From the included studies, at the median pre-test probability of common bile duct stones of 41% the post-test probabilities (with 95% CI) associated with positive and negative EUS test results were 0.96 (95% CI 0.92 to 0.98) and 0.03 (95% CI 0.02 to 0.06). At the same pre-test probability, the post-test probabilities associated with positive and negative MRCP test results were 0.94 (95% CI 0.87 to 0.97) and 0.05 (95% CI 0.03 to 0.09). AUTHORS' CONCLUSIONS Both EUS and MRCP have high diagnostic accuracy for detection of common bile duct stones. People with positive EUS or MRCP should undergo endoscopic or surgical extraction of common bile duct stones and those with negative EUS or MRCP do not need further invasive tests. However, if the symptoms persist, further investigations will be indicated. The two tests are similar in terms of diagnostic accuracy and the choice of which test to use will be informed by availability and contra-indications to each test. However, it should be noted that the results are based on studies of poor methodological quality and so the results should be interpreted with caution. Further studies that are of high methodological quality are necessary to determine the diagnostic accuracy of EUS and MRCP for the diagnosis of common bile duct stones.
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Affiliation(s)
- Vanja Giljaca
- Clinical Hospital Centre RijekaDepartment of GastroenterologyKresimirova 42RijekaCroatia51000
| | - Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
| | - Yemisi Takwoingi
- University of BirminghamPublic Health, Epidemiology and BiostatisticsEdgbastonBirminghamUKB15 2TT
| | - David Higgie
- North Bristol NHS TrustFrenchay HospitalBristolUKBS16 1LE
| | - Goran Poropat
- Clinical Hospital Centre RijekaDepartment of GastroenterologyKresimirova 42RijekaCroatia51000
| | - Davor Štimac
- Clinical Hospital Centre RijekaDepartment of GastroenterologyKresimirova 42RijekaCroatia51000
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
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Bektas H, Duzkoylu Y, Cakar E, Buyukasık K, Colak S. Giant choledochal calculosis: surgical treatment. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2014; 6:536-9. [PMID: 25489567 PMCID: PMC4215492 DOI: 10.4103/1947-2714.143286] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Context: Gallstone disease is one of the most common surgical pathologies. Choledocholithiasis may occur in some of these cases and require surgical intervention. Although there are relatively non-invasive procedures such as endoscopic retrograde cholangiopancreatography (ERCP), this technique is usually unsuccessful in patients with stones larger than 10 mm. In our case, we aimed to report a giant choledochal stone (15 cm × 4.5 cm), which is rare in surgical practice and our treatment with open surgery. Case Report: The patient was a 59-year-old woman. Magnetic resonance cholangiopancreatography (MRCP) had showed a hydropic gallbladder with an excessively dilated CBD and a 110 mm × 41 mm stone. In the operation, an excessively dilated CBD was seen and after choledochotomy and a very large calculus that filled CBD completely. Choledochotomy incision was carried forward and a T-tube choledochostomy with choledochoduodenostomy (CD) was performed. The patient was discharged without any complications on postoperative 8th day. Conclusion: Benign gallstone disease is a multifactorial process, with risk factors such as obesity, hemolytic diseases, diabetes mellitus, and pregnancy. Risk factors for choledocholithiasis are similar to those for gallstone disease. MRCP is a non-invasive technique in detecting choledocholithiasis. The gold standard intervention for CBD stones is ERCP. Stones in CBD may reach very considerable dimensions without causing serious symptoms. The most common symptom is jaundice. During preoperative radiological examination, giant stones may be interfered with malignancies. Surgeons should obey conventional algorithms in diagnosis and open surgery must be kept in mind in earlier stages without being too insistent on endoscopic interventions.
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Affiliation(s)
- Hasan Bektas
- Istanbul Training and Research Hospital, General Surgery Department, İstanbul, Turkey
| | - Yigit Duzkoylu
- Istanbul Training and Research Hospital, General Surgery Department, İstanbul, Turkey
| | - Ekrem Cakar
- Istanbul Training and Research Hospital, General Surgery Department, İstanbul, Turkey
| | - Kenan Buyukasık
- Istanbul Training and Research Hospital, General Surgery Department, İstanbul, Turkey
| | - Sukru Colak
- Istanbul Training and Research Hospital, General Surgery Department, İstanbul, Turkey
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Costi R, Gnocchi A, Di Mario F, Sarli L. Diagnosis and management of choledocholithiasis in the golden age of imaging, endoscopy and laparoscopy. World J Gastroenterol 2014; 20:13382-13401. [PMID: 25309071 PMCID: PMC4188892 DOI: 10.3748/wjg.v20.i37.13382] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 03/23/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
Biliary lithiasis is an endemic condition in both Western and Eastern countries, in some studies affecting 20% of the general population. In up to 20% of cases, gallbladder stones are associated with common bile duct stones (CBDS), which are asymptomatic in up to one half of cases. Despite the wide variety of examinations and techniques available nowadays, two main open issues remain without a clear answer: how to cost-effectively diagnose CBDS and, when they are finally found, how to deal with them. CBDS diagnosis and management has radically changed over the last 30 years, following the dramatic diffusion of imaging, including endoscopic ultrasound (EUS) and magnetic resonance cholangiography (MRC), endoscopy and laparoscopy. Since accuracy, invasiveness, potential therapeutic use and cost-effectiveness of imaging techniques used to identify CBDS increase together in a parallel way, the concept of "risk of carrying CBDS" has become pivotal to identifying the most appropriate management of a specific patient in order to avoid the risk of "under-studying" by poor diagnostic work up or "over-studying" by excessively invasive examinations. The risk of carrying CBDS is deduced by symptoms, liver/pancreas serology and ultrasound. "Low risk" patients do not require further examination before laparoscopic cholecystectomy. Two main "philosophical approaches" face each other for patients with an "intermediate to high risk" of carrying CBDS: on one hand, the "laparoscopy-first" approach, which mainly relies on intraoperative cholangiography for diagnosis and laparoscopic common bile duct exploration for treatment, and, on the other hand, the "endoscopy-first" attitude, variously referring to MRC, EUS and/or endoscopic retrograde cholangiography for diagnosis and endoscopic sphincterotomy for management. Concerning CBDS diagnosis, intraoperative cholangiography, EUS and MRC are reported to have similar results. Regarding management, the recent literature seems to show better short and long term outcome of surgery in terms of retained stones and need for further procedures. Nevertheless, open surgery is invasive, whereas the laparoscopic common bile duct clearance is time consuming, technically demanding and involves dedicated instruments. Thus, although no consensus has been achieved and CBDS management seems more conditioned by the availability of instrumentation, personnel and skills than cost-effectiveness, endoscopic treatment is largely preferred worldwide.
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Body mass index, cholecystitis, cholelithiasis, pancreatitis and imaging of common bile duct stones. Am J Med Sci 2014; 347:364-9. [PMID: 23838577 DOI: 10.1097/maj.0b013e318296a6fe] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE Studies to date have not investigated whether body mass index (BMI) affects the sensitivity and specificity of magnetic resonance cholangiopancreatography (MRCP). The purpose of this study was to investigate the effect of BMI and also concomitant pancreatitis, cholecystitis and cholelithiasis on the sensitivity and specificity of MRCP. MATERIALS AND METHODS Between January 2004 and December 2011, 185 patients were included in the study and divided into 3 groups according to BMI as normal, overweight or obese. Both MRCP and endoscopic retrograde cholangiopancreatography (ERCP) were performed in all patients. ERCP was accepted as the "gold standard." The accuracy, sensitivity and specificity values of the 3 groups were calculated to determine any effects on the results of the MRCP. RESULTS Before separating into groups according to BMI, the statistical results for MRCP in the detection of stone disease were as follows: specificity 74.3%, sensitivity 81.7% and accuracy 79%. After dividing the patients into 3 groups according to BMI, the specificity of stone detection with MRCP in the normal-weight group was 93.8% but decreased to 65.5% in the overweight group and to 72% in the obese group. The sensitivity of stone detection with MRCP in the normal-weight group was 85.2% but decreased to 75% in the overweight group and increased to 88.9% in the obese group. The accuracy was 88.3% in the normal-weight group but decreased to 71.6% in the overweight group and to 81.9% in the obese group. CONCLUSION Our study showed that MRCP performance was decreased in the overweight and obese groups.
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Wilcox CM, Kim H, Trevino J, Ramesh J, Monkemuller K, Varadarajulu S. Prevalence of normal liver tests in patients with choledocholithiasis undergoing endoscopic retrograde cholangiopancreatography. Digestion 2014; 89:232-238. [PMID: 24903214 DOI: 10.1159/000358384] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 01/06/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS Abnormal liver chemistry tests are a hallmark of common bile duct (CBD) stones. There is little information, however, on the prevalence of and predictors for normal liver chemistry tests in such patients. METHODS Over an 11-year period, all patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) at our Center were prospectively identified. Patients in this study were those with CBD stones found at ERCP and where the indication for ERCP was CBD stones seen on imaging studies or when CBD stones were highly suspected based upon clinical presentation and radiographic and laboratory findings. Liver chemistry tests were recorded from those taken at the time of initial presentation as well as the time closest to ERCP. RESULTS Of a total of 5,133 patients undergoing ERCP during the study period, the indication was suspicion for CBD stones or for radiographically identified CBD stones in 476 and 593, respectively, with 115 patients having both indications. Of these 1184 patients, 765 had CBD stones of whom 541 had liver tests. Of these 541, 29 patients (5.4%) were found to consistently have normal liver chemistry tests. Multivariate analysis identified two factors predictive of normal liver tests including age >55 years and the presence of abdominal pain. CONCLUSIONS Although rare, liver tests can be normal in patients with CBD stones. Patients most likely to have normal liver tests included older patients and those with abdominal pain.
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Affiliation(s)
- Charles Mel Wilcox
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Ala., USA
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26
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Ćwik G, Wyroślak-Najs J, Skoczylas T, Wallner G. Significance of ultrasonography in selecting methods for the treatment of acute cholecystitis. J Ultrason 2013; 13:282-92. [PMID: 26674665 PMCID: PMC4603224 DOI: 10.15557/jou.2013.0029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Revised: 10/18/2012] [Accepted: 10/29/2012] [Indexed: 11/22/2022] Open
Abstract
Surgical removal of the gallbladder is indicated in nearly all cases of complicated acute cholecystitis. In the 1990s, laparoscopic cholecystectomy became the method of choice in the treatment of cholecystolithiasis. Due to a large inflammatory reaction in the course of acute inflammation, a laparoscopic procedure is conducted in technically difficult conditions and entails the risk of complications.
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Affiliation(s)
- Grzegorz Ćwik
- II Katedra i Klinika Chirurgii Ogólnej, Gastroenterologicznej i Nowotworów Układu Pokarmowego, Uniwersytet Medyczny w Lublinie, Lublin, Polska
| | - Justyna Wyroślak-Najs
- II Katedra i Klinika Chirurgii Ogólnej, Gastroenterologicznej i Nowotworów Układu Pokarmowego, Uniwersytet Medyczny w Lublinie, Lublin, Polska
| | - Tomasz Skoczylas
- II Katedra i Klinika Chirurgii Ogólnej, Gastroenterologicznej i Nowotworów Układu Pokarmowego, Uniwersytet Medyczny w Lublinie, Lublin, Polska
| | - Grzegorz Wallner
- II Katedra i Klinika Chirurgii Ogólnej, Gastroenterologicznej i Nowotworów Układu Pokarmowego, Uniwersytet Medyczny w Lublinie, Lublin, Polska
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Jones M, Johnson M, Samourjian E, Schlauch K, Ozobia N. ERCP and laparoscopic cholecystectomy in a combined (one-step) procedure: a random comparison to the standard (two-step) procedure. Surg Endosc 2012; 27:1907-12. [PMID: 23239300 DOI: 10.1007/s00464-012-2647-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 10/10/2012] [Indexed: 01/16/2023]
Abstract
BACKGROUND Current treatment of complicated calculous biliary disease typically involves a two-step procedure consisting of preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy. Alternatively, laparoscopic cholecystectomy with intraoperative cholangiogram (IOC) and intraoperative common bile duct exploration or ERCP at a later date may be performed. This study compared the benefits of the traditional two-step procedure to the novel one-step procedure for the management of calculous biliary disease. METHODS A retrospective review of 20 patients was conducted comparing one-step to two-step procedures for the management of choledocholithiasis. We define the one-step procedure to be a laparoscopic cholecystectomy with IOC to confirm the presence or absence of stones. Intraoperative ERCP with stone extraction was conducted if necessary as part of the one-step procedure. RESULTS A statistically significant difference existed between hospital charges for one-step ($58,145.30, SD $17,963.09) and two-step ($78,895.53, SD $21,954.78) procedures (p = 0.033). Other parameters (length of stay, preoperative days) trended toward significance; however, statistical significance was not achieved. CONCLUSIONS There appears to be a significant cost reduction with implementation of the one-step treatment of calculous biliary disease. Further research with a larger study population is necessary to determine the additional benefits of this procedure and to help augment the surgical endoscopists' armamentarium.
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Affiliation(s)
- Maris Jones
- Department of Surgery, University of Nevada School of Medicine, 2040 W Charleston Blvd Suite 301, Las Vegas, NV 89102, USA.
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