02.10.

2016

LaparoscopicmanagementofconcomitantgallstonesandcommonbileductstonescurrentpracticeandourexperienceEMCB
Contribuie

Cautareavansata

Statisticisite

Arhiva

Resurseweb

Sondaje

emecebereloaded

cautareavansata Cauta
ModulEMCactiv
ModulReumatologie
Arhiva
Paginaprincipala
AnunturiEMCB(32/0)
Publicatiimedicale(18/0)
EMCReumatologie(8/0)
Biochimie(0/0)
Boliinfectioase(16/0)
Cardiologie(18/0)
ChirurgieBMF(3/0)
Chirurgiegenerala(47/0)
Chirurgiepediatrica(6/0)
Chirurgietoracica(1/0)
Dermatologie(7/0)
Endocrinologie(3/0)
Farmacologie(0/0)
Fiziologie(1/0)
Gastroenterologie(21/0)
Hematologie(4/0)
Imunologie(7/0)
Internet(8/0)
Medicinainterna(27/0)
Manifestaristiintifice(38/0)
Medicinafamiliei(0/0)
Medicinalegala(2/0)
Medicinamuncii(0/0)
Medicinasportiva(1/0)
Microbiologie(0/0)
Neurochirurgie(1/0)
Nefrologie(3/0)
Neurologie(9/0)
ObstGinecologie(13/0)
Oftalmologie(2/0)
Ortopedie(2/0)
Otorinolaringologie(2/0)
Stirigenerale(15/0)
Pediatrie(19/0)
Psihiatrie(13/0)
ResurseEMC(18/0)
SanatatePublica(13/0)
Urgente(4/0)
Urologie(2/0)
Pneumologie(18/0)

Info
Termeniutilizare
Inscrieresiregulament
Intrebarifrecvente
Consiliuderedactie
Contact
Dateutilizator
Nume:
Parola:

BineaivenitlaEMCB
02.10.2016,18:59
Home>Chirurgiegenerala

Laparoscopicmanagementofconcomitantgallstonesand
commonbileductstonescurrentpracticeandour
experience
07.04.2015,17:10
Afisari1,340

BVMartian,BIDiaconescu,MBeuran
EmergencyClinicalHospitalBucharest"Floreasca"
Summary:Despitemanyadvancesinthelastdecadestheoptimaltreatment
forconcomitantgallstonesandcommonbileduct(CBD)stonesisstillcontroversial.
Whilefortheasymptomaticgallbladderstonestheneedforsurgeryisstillunder
debate,thereislargeconsensusregardingtheindicationtoremovetheCBDstones,
whichappeartobeassociatedin310%ofpatients(1).
BeforethelaparoscopicerathestandardtreatmentforCBDstoneswasopen
cholecystectomyandCBDexploration.Forthepatientsunfitforsurgery,orwith
severecomplicationssuchasacutecholangitis,jaundiceandpancreatitis,ERCPwith
endoscopicsphincterotomy(ES)andstoneextractionwasavaluable,seldomstand
alone,lifesaving,alternative.Withtheadventoflaparoscopiccholecystectomy(LC)in
19871988,newtechniquesaddedtothearmamentariumofCBDstonestreatment.
Reddick&Olsen(2,3)sustainedtheERCPwithendoscopicsphincterotomy(ES)and
stoneextractionasearlyas1990Petelin(4),almostsimultaneously,introducedthe
laparoscopicCBDexploration(LCBDE).Thecurrentstandardsofpracticerecognise3
options:thecombinedlaparoendoscopic,thetotallylaparoscopicandtheopen
approach.ThepresentpaperisaimingtodiscusstheseoptionswithafocusonLCBE.
Thechoicebetweenthe3optionsisdependingonmanyfactors,giventhefinal
objectivetoobtainCBDclearanceinthesafestway,withminimalpatientaggression
andinthemostcosteffectivemanner.
Thefirstaspecttodiscussisthestonedetectionmoment:preoperative,intraor
postoperative.ThepreoperativeCBDstonesdiagnosisisproblematic.Themost
predictivesignappearstobeacutecholangitis,withupto100%CBDstonespresent
(5).TheclinicalsignssuggestiveforCBDstonessuchascholecystitis,biliarycolic,
acutepancreatitisandjaundiceprovedtobeassociatedwithstonesin7%,16%,
20%and45%ofcasesrespectively(5).Thecaseissimilarforthelabtests,withup
to50%falsepositive/negativeresults.ThestandardtransabdominalUS,whilevery
sensibleinshowinggallbladderstoneshasonly5080%specificityindetectingCBD
stonesand,inaddition,isveryoperatordependent.Fromtheoppositeperspectiveit
hasbeendemonstratedon1000consecutiveLCwithintraoperativecholangiography
(IOC)andunsuspectedCBDstonesthepresenceofcalculiin14.2%ofcases(5).
Thus,confirmationtestsarenecessaryforpreoperativedetection.
ERCPishighlysensitive(9095%)indetectingCBDstonesandextractingthem(over
90%)whenESisassociated.However,itisaninvasiveprocedureandhasbeen
showntohavesignificantpostproceduralmorbiditybleeding,perforation,acute
pancreatitisin16%ofcases,evenrelatedmortalityin1%(6).Additionally,evenif
strictcriteriabasedonhighsuspicionindexforCBDstonesareused,only1060%of
patientswillactuallyhavestonesatthetimeofES(7,8).Asaresult,anumberof
unnecessaryERCPESproceduresarebeingperformed,withtheirownmorbi
mortality.Currently,ERCPisnolongeracceptedforCBDstonesdetectionitisa
valuableinstrumentforpreoperativeuseinpatientswithconfirmedstones,for
treatmentpurposesonly(9).SomeauthorshaveadvocatedESeitherconcomitant,or
postLC(stonesdetectedbyIOCoroperativeUS),thusavoidingtheunnecessary
ERCPES.Thereareclearadvantages,yetpostERCPmorbidity&mortalityremainthe

https://www.emcb.ro/article.php?story=20150407171019794

1/4

02.10.2016

Intra/Login

Aiuitatparola?

LaparoscopicmanagementofconcomitantgallstonesandcommonbileductstonescurrentpracticeandourexperienceEMCB

same(10).
EUSisamorerecentvaluablediagnostictest.Somecentreswhichperformroutinely
preoperativeEUSreport98%sensitivityand99%specificity(11).Theproblemis,
morethanforconventionalUS,theoperatordependancy.Nevertheless,intrained
centres,itanexcellentalternativeforpreoperativestonedetection.
Magneticresonancecholangiopancreatography(MRCP)isanotheralternatediagnostic
testwith95100%accuracyindetectingCBDstones(12).Itisnoninvasive,less
operatordependentandconsideredthecurrentdiagnosticstandardforpatientswith
mediumtohighsuspicionindexforcholedocolithiasis(9).TheproblemswithMRCP
areavailabilityandhighcostwhichlimititsusage.ShortsequenceMRCPmightlimit
costwithoutimpedingonaccuracy(12).
Helicalcomputedtomography(HCT)isanewertest,withcomparablevaluetoMRCP
(13).Thedisadvantageislinkedwithcontrastinjection.
Diffrentmodalitiesforsuccesfullytreatingcommonbileductstonesareaccepted.The
appropiatetherapydependsonthepatient&#8217sconditionandmoreimportant
theequipment,localexpertiseinlaparoscopy,endoscopyandinterventionalradiology.
Practicetherearerecognisedthreeoptions:thecombinedlaparoendoscopicwith
endoscopypriortosurgery,thetotallylaparoscopicandtheopenapproach.Noble
designedonetrialtocomparesinglestage(LC+LCBDE)aproachwithtwostage
(ERCP+LC)aproachinhigherriskpatient(over50yearswithBMIhigherthan40,
over60yearswithcomorbidityorthoseover70years).(14)Patientswithsevere
pancreatitisandcholangitisorwichrequireemergencyERCPwereexcluded.
Endoscopicretrogradecolangiographyplaysanimportantroleintheearlytreatment
ofcommonbileductstonesforpatientswithjaundice,cholangitisorsevere
pancreatitis.Alsoforpatientswithelderlywhomaynottolerateanoperation,
performingERCPandleavingthegallbladderinsituisanalternativebutwithalotof
risks.HowevertheroutineERCPforsuspectedcholedocholithiasisisnotaccepted.
Therearesomestudieswhodemonstatethatupto61%ofpatientswithsuspected
commonductstonesundergoanunnecessaryERCPanddwichmaybeisassociated
withmorbities.(15)
MuchofthemorbiditylinkedwithERC/ESisassociatedwiththesphincterotomy.
Endoscopicpapillarydilationhasbeensuggestedasanalternativehowever,arecent
multicenter,controlledrandomizedstudydemonstratedthatendoscopicballoon
dilatationresultedinahigherrateofpancreatitiscomparedwithsphincterotomyand
recommendedthatitshouldbeavoidedinroutinepractice.(16)
LaparoscopicCBDexplorationcantakeplaceviathecysticduct(transcystictechnique)
orbydirectlyincisingandopeningtheCBDwithstoneretrieval(laparoscopic
choledochotomy).Smallstonescanoftenbe&#64258ushedthroughtheampullainto
theduodenum.IntravenousglucagonmaybeusedtorelaxthesphincterofOddi,
followedby&#64258ushingof100&#8211200mlofsaline.Whenthesemethods
fail,ahelicalstonebasketcanbepassedoveraguidewirethroughthecysticduct
andintotheCBDtoextractstonesunder&#64258uoroscopicguidance.Ifattempts
attranscysticbasketextractionfail,acholedochoscope(<10Fr)shouldbetriednext
toremovethestonesunderdirectvision.IftheCBDstoneislargerthanthelumenof
thecysticduct,thecysticductshould&#64257rstbeballoondilatedtoamaximum
of8mmdiameter,butneverlargerthantheinternaldiameteroftheCBD.(17)
Ifthetranscysticapproachfails,werecommendlaparoscopiclongitudinal
choledochotomy.Indicationsforcholedochotomyaremultipleorlargestoneswith
smalldistalCBPorthosepositionedwithintheproximalbileductsinpatientswitha
CBDdiameterlargerthan8&#821110mm.Choledochoraphyisaccomplishedwith
&#64257neabsorbablesuturesbyusingintracorporealsuturingtechniquesandifa
Ttubeisused,itisexteriorizedthroughthelateralportsite.Othershaveshown
decreasedcomplicationswithprimaryclosurecomparedwithTtubeuse.
Thepatientisgenerallydischarged2&#82114dayspostoperatively.IfaTtubeis
used,a&#64257nalcholangiogramisperformed23weakspostoperativelywith
removalofthetubeifnoabnormalitiesarefound.Othershaveshowndecreased
complicationswithprimaryclosurecomparedwithTtubeuse.(18)
Prospectiverandomizedtrialcomparingtwostageswithsingle&#8211stage
managementdemonstrateequivalentsuccesrateforlaparoscopiccommonbileduct
explorationversusERCPfollowedbylaparoscopiccholecystectomywithreduced
hospitalstayforlaparoscopy.(19)
OpenCBDexplorationshouldbeconsideredthegoodtechniqueadaptedtolocal
situation,nota&#8216&#8216failure&#8217&#8217,iflaparoscopicCBDE
and/orpostoperativeERCareunsuccessful.Themostcommonreasontoconvertto

https://www.emcb.ro/article.php?story=20150407171019794

2/4

02.10.2016

LaparoscopicmanagementofconcomitantgallstonesandcommonbileductstonescurrentpracticeandourexperienceEMCB

openCBDEisanimpactedstoneattheampullaofVater,andthesecasesrequirea
transduodenalexploration.OpenCBDEshouldalsobeconsideredastheinitial
procedureofchoiceifpatientspresentwithdilatedCBDormultiplecommonbileduct
stones.Thisentailseitherperformingacholedochoenterostomy.
InEmergencyClinicalHospitalFloreascamagneticresonance
cholangiopancreatography(MRCP)and,whenitisnotavailable,computed
tomographyhavebeenusedtodiagnosecholedocholithiasis.Alsointraoperative
cholangiographyisusedinselectivecases.DiagnosticERCPisabandoned.Regarding
ourexperiencethestandardisSE+CL.
TheexperiencewithLCBDEislimitedtoasinglesurgicalteamanditisoccasionally
becauseoffinancialdifficulties.Between2001and2008,108patientswereoperated
inlaparoscopicaproach.Theexclusioncriteriawerepapillaryimpaction,acute
pancreatitis,acutecholangitisorotherseverecomorbidities.Thediagnosiswas
confirmedbyMRCPin69patients,8patientsbyultrasoundandin32casesby
cholangiography.In40casesweusedcholedochoscopeandweconfirmedthe
choledocholithiasis.Thefirstchoiceforusisremovethestonesbytranscystic
approachbecauseitistechnicallysimple,iseffectiveinmorethan85%ofcasesand
doesnotaffectCBP.Laparoscopiccoledocotomywasperformedfor63patients
gettingclearancein62cases.
Opensurgeryremainsanoptionforfailureofminimallyinvasivemethods,
intrahepaticlithiasis,complexCBPlithiasisorinparticularcasesofacutecholangitis.
Conclusions
Choledocolithiasisremainsacomplicatedandchallengingdiseasewithatreatments
whichdependsonoperatorexpertiseandavailableresources.Singlestageis
equivalentintermsofresultsaboutpostoperativemorbidityandmortalitywithtwo
stagestherapybutreducesthenumberofproceduresperpatients.
References
1.CollinsC,MaguireD,IrelandA,FitzgeraldE,O&#8217SullivanGC.Aprospective
studyofcommonbileductcalculiinpatientsundergoinglaparoscopic
cholecystectomy:naturalhistoryofcholedocholithiasisrevisited.AnnSurg2004239:
2833
2.ReddickEJ,OlsenDO,AlexanderW,etal.(1990)Laparoscopiclaser
cholecystectomyandcholedocholithiasis.SurgEndosc(1988)4:133134
3.CuschieriA,DuboisF,MouielJ,etal.(1991)TheEuropeanexperiencewith
laparoscopiccholecystectomy.AmJSurg161:385387
4.PetelinJB(1991)Laparoscopicapproachtocommonductpathology.SurgLaparosc
Endosc2:3341.
5.TranterSE,ThompsonMH.Spontaneouspassageofbileductstones:Frequencyof
occurrenceandrelationtoclinicalpresentation.AnnRCollSurgEngl
200385:174&#8211177.
6.Wangp,LiZS,liuFetal.RiskfactorsforERCPrelatedcomplications:aprospective
multicenterstudy.AmJGastroenterol2009104:3140
7.BergamaschiR,TuechJJ,BraconierL,Wals&#248eHK,M&#229rvikR,BoyetJ,
ArnaudJP.Selectiveendoscopicretrogradecholangiographypriortolaparoscopic
cholecystectomyforgallstones.AmJSurg1999178:4649
8.CoppolaR,RiccioniME,CilettiS,CosentinoL,RipettiV,MagistrelliP,PicciocchiA.
Selectiveuseofendoscopicretrogradecholangiopancreatographytofacilitate
laparoscopiccholecystectomywithoutcholangiography.Areviewof1139consecutive
cases.SurgEndosc200115:12131216
9.EAMNeugebauer,SSauerland,AFingerhut,BMillat,GBuess.EAESGuidelinesfor
EndoscopicSurgery,Springer2006,p330
10.VandervoortJ,SoetiknoRM,ThamTC,WongRC,FerrariAP,MontesH,Roston
AD,SlivkaA,LichtensteinDR,RuymannFW,VanDamJ,HughesM,CarrLockeDL.
RiskfactorsforcomplicationsafterperformanceofERCP.GastrointestEndosc2002
56:652656
11.BuscariniE,TansiniP,VallisaD,ZambelliA,BuscariniL.EUSforsuspected
choledocholithiasis:dobenefitsoutweighcosts?Aprospective,controlledstudy.
GastrointestEndosc200357:510&#8211518.
12.ShamiyehA,LinderE,DanisJ,etal.ShortversuslongsequenceMRI
cholangiographyforthepreoperativeimagingofthecommonbileductinpatientswith
cholecystolithiasis.SurgEndosc200519:1130&#82111134.
https://www.emcb.ro/article.php?story=20150407171019794

3/4

02.10.2016

LaparoscopicmanagementofconcomitantgallstonesandcommonbileductstonescurrentpracticeandourexperienceEMCB

13.KondoS,IsayamaH,AkahaneM,etal.Detectionofcommonbileductstones:
comparisonbetweenendoscopicultrasonography,magneticresonance
cholangiography,andhelicalcomputedtomographiccholangiography.EurJRadiol
200554:271&#8211275.
14.NobleH,TranterS,ChesworthT,NortonS,ThompsonM.Arandomized,clinical
trialtocompareendoscopicsphincterotomyandsubsequentlaparoscopic
cholecystectomywithprimarylaparoscopicbileductexplorationduring
cholecystectomyinhigherriskpatientswithcholedocholithiasis.JLaparoendoscAdv
SurgTechA200919:713720
15.NatalyY.MerrieAE,StewartIDSelectiveuseofpreoperativeendoscopic
retrogradecholangiopancreatographyintheeraoflaparoscopiccholecistectomyANZ
JSurg2002,72:186189
16.TaiCK,TangCN,HaJP,ChauCH,SiuWT,LiMK.Laparoscopicexplorationof
commonbileductindif&#64257cultcholedocholithiasis.SurgEndosc
200418:910&#8211914.
17.HunterJG,SoperNJ.Laparoscopicmanagementofcommonbileductstones.
SurgClinNorthAm199272:1077&#82111097.
18.PetelinJB.Laparoscopiccommonbileductexploration.SurgEndosc
200317:1705&#82111715.
19.CuscheriA,LezocheE,MorinoM,etallEAESmulticenterprospectiverandomized
trialcomparingtwostagesvssinglestagemanagementofpatientswithgallstone
diseaseandductalcalculi.Surg.Endosc1999,13:952957
20.ManagementofCommonBileDuctStones,EricS.Hungness,M.D.,NathanielJ.
Soper,M.D.JournalofGastrointestinalsurgeryVol10,2006,nr4,612619
Linkuri
MaimultdespreChirurgiegenerala

Optiunistire
Paginainformatpentruimprimanta

Copyright2016EMCB
Toatemarcileintregistratesidrepturiledeautordinaceastapaginasintdetinutedecatreproprietarii
lordedrept.

https://www.emcb.ro/article.php?story=20150407171019794

PoweredbyGeeklog
Paginageneratain0.16secunde

4/4