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Cholecystocholedocholithiasis: a case–control study comparing the short- and long-term outcomes for a “laparoscopy-first” attitude with the outcome for sequential treatment (systematic endoscopic sphincterotomy followed by laparoscopic cholecystectomy)

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Abstract

Background

No unanimous consensus has been achieved regarding the ideal management of cholecystocholedocholithiasis. The treatment of gallbladder and common bile duct (CBD) stones may be achieved currently according to a two-step-protocol (endoscopic sphincterotomy associated with laparoscopic cholecystectomy) or by a one-step laparoscopic procedure, including exploration of the CBD and cholecystectomy. Endoscopic sphincterotomy is reported to have considerable morbidity/mortality and CBD stone recurrence rates, whereas laparoscopic CBD clearance is a demanding procedure, which to date has not spread beyond specialized environments.

Methods

To evaluate our “laparoscopy first” (LF) approach for patients affected by gallbladder/CBD stones (laparoscopic exploration and intraoperative decision whether to proceed with laparoscopic CBD exploration or to postpone CBD stone treatment to a postoperative endoscopic retrograde cholangiopancreatography [ERCP]), we performed a retrospective, two-center case–control comparison of the postoperative outcome for 49 consecutive patients treated for gallbladder/CBD stones from January 2000 through December 2004. The results obtained with this LF approach were compared with those achieved with the traditional, “endoscopy-first” (EF) approach (ERCP plus endoscopic sphincterotomy, followed by laparoscopic cholecystectomy). The mean follow-up period was 6.4 years (range, 4–8 years).

Results

No difference emerged concerning early and late complications, mortality, or laparotomies needed to accomplish cholecystectomy and CBD clearance. The postoperative hospital stay was shorter for the LF group. In the LF group, only 22 patients underwent choledochotomy (45%), and 15 patients underwent perioperative ERCP (30%). Conversions decreased with practice. After choledochotomy, an increasing number of patients underwent primary closure of the CBD (with no biliary drain), without complications.

Conclusions

An LF approach to gallbladder/CBD stones is safe and feasible. It may allow the majority of surgeons to avoid excessively difficult/dangerous surgical procedures as well as unnecessary ERCPs in most cases. A tendency toward a lower incidence of conversions and a rarer use of biliary drains may lead to an improved immediate outcome for patients undergoing an LF approach.

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Notes

  1. LC (both groups): The LC procedure was performed according to a traditional laparoscopic approach. The operating surgeon was located between the legs of the patient, who was placed in 30°-anti-Trendelenburg/15° left lateral decubitus position. Pneumoperitoneum was induced by open technique or Hasson/Veress needle, and a 0° or 30° laparoscope was used according to the surgeon’s preference. Four trocars (two 10 mm and two 5 mm) were used in all cases. Cholecystectomy was performed by monopolar electrocautery (hook). If the gallbladder was perforated during cholecystectomy or extraction, every effort was made to retrieve all the spilled stones. The bile was aspirated and the abdominal cavity washed. The cystic duct and artery were dissected, clipped (metallic clips), and sectioned with scissors (in the EF group, before sectioning of the cystic duct, a routine intraoperative cholangiogram was performed and, if needed, CBD stones were treated laparoscopically; see earlier). No drain was used unless a procedure on the choledochus was performed (LF group). At the end of surgery, neither nasogastric suction nor urinary catheter was left in place.

  2. ERCP followed by endoscopic sphincterotomy (both groups): The ERCP procedure was performed with the patient under sedation (e.g., meperidin, midazolam) or narcosis (e.g., fentanyl, propofol). A nasotracheal tube was inserted. A lateral view endoscope was inserted into the second duodenal portion. The choledochus was catheterized through Vater’s papilla under X-ray control, and cholangiography was performed. A guidewire was inserted into the choledochus through the catheter, which was subsequently removed. Endoscopic sphincterotomy by electrocautery was performed, followed by stone basket extraction (Dormia basket) after confirmation of the CBD stones. Endoscopy was performed by gastroenterologists and not by surgeons.

  3. See footnote 1.

  4. See footnote 2.

  5. Open approach to gallbladder and CBD stones (EF group): A right subcostal laparotomy was performed. After the dissection of the cystic duct and artery, an intraoperative cholangiogram was performed. On the basis of CBD size; the size, number, and location of CBD stones; the presence of local complications; and the age/health status of the patient, the operating surgeon decided whether to proceed to (1) papillosphincterotomy by duodenotomy or (2) choledochojejunal anastomosis (cholecystectomy was performed in both cases):

    (1) Papillosphincterotomy by duodenotomy. After mobilization of the duodenum, a Fogarty catheter (with a 2.5-ml balloon) was introduced through the cystic duct and pushed up and down to retrieve all CBD stones. It then was pushed down the CBD until it could be felt against the duodenal wall. This served as a reference point from which a minimal transversal duodenotomy was performed with subsequent recovery of the Fogarty balloon. After the papilla was exposed, a 1-cm vertical sphincterotomy was performed and easily sutured as a sphincteroplasty by three separate stitches (Vicryl 3/0). Once the procedure was completed, the duodenal wall was closed transversally using a two-layered reabsorbable suture (Vycril 3/0). One periduodenal drain was used, which was removed on postoperative day 9.

    (2) Choledochojejunal anastomosis. After a 2-cm longitudinal choledochotomy, a Fogarty catheter (with a 2.5-ml balloon) was introduced through the cystic duct to retrieve CBD stones. Regardless whether CBD clearance was achieved, a transmesocolic laterolateral choledochojejunal anastomosis was performed (Vicryl 4/0, separate stitches). One perianastomotic drain was used, which was removed on postoperative day 7.

References

  1. Martin DJ, Vernon DR, Toouli J (2006) Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev (2):CD003327

  2. Scientific Committee of the European Association for Endoscopic Surgery (E.A.E.S.) (1998) Diagnosis and treatment of common bile duct stones (CBDS): results of a consensus development conference. Surg Endosc 12:856–864

    Article  Google Scholar 

  3. Morino M, Baracchi F, Miglietta C, Furlan N, Ragona R, Garbarini A (2006) Preoperative endoscopic sphincterotomy versus laparoendoscopic rendezvous in patients with gallbladder and bile duct stones. Ann Surg 244:889–893

    Article  PubMed  Google Scholar 

  4. Clayton ES, Connor S, Alexakis N, Leandros E (2006) Meta-analysis of endoscopy and surgery versus surgery alone for common bile duct stones with the gallbladder in situ. Br J Surg 93:1185–1191

    Article  CAS  PubMed  Google Scholar 

  5. Barwood NT, Valinsky LJ, Hobbs MS, Fletcher DR, Knuiman MW, Ridout SC (2002) Changing methods of imaging the common bile duct in the laparoscopic cholecystectomy era in Western Australia: implications for surgical practice. Ann Surg 235:41–50

    Article  PubMed  Google Scholar 

  6. Ghazi A, McSherry CK (1984) Endoscopic retrograde cholangiopancreatography and sphincterotomy. Ann Surg 199:21–27

    Article  CAS  PubMed  Google Scholar 

  7. Rhodes M, Sussman L, Cohen L, Lewis MP (1998) Randomised trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde cholangiography for common bile duct stones. Lancet 351:159–161

    Article  CAS  PubMed  Google Scholar 

  8. Heinerman PM, Boeckl O, Pimpl W (1989) Selective ERCP and preoperative stone removal in bile duct surgery. Ann Surg 209:267–272

    Article  CAS  PubMed  Google Scholar 

  9. Ong TZ, Khor JL, Selamat DS, Yeoh KG, Ho KY (2005) Complications of endoscopic retrograde cholangiography in the post-MRCP era: a tertiary center experience. World J Gastroenterol 11:5209–5212

    PubMed  Google Scholar 

  10. Freeman ML, Nelson DB, Sherman S, Haber GB, Herman ME, Dorsher PJ, Moore JP, Fennerty MB, Ryan ME, Shaw MJ, Lande JD, Pheley AM (1996) Complications of endoscopic biliary sphincterotomy. N Engl J Med 335:909–918

    Article  CAS  PubMed  Google Scholar 

  11. Rábago LR, Vicente C, Soler F, Delgado M, Moral I, Guerra I, Castro JL, Quintanilla E, Romeo J, Llorente R, Vázquez Echarri J, Martínez-Veiga JL, Gea F (2006) Two-stage treatment with preoperative endoscopic retrograde cholangiopancreatography (ERCP) compared with single-stage treatment with intraoperative ERCP for patients with symptomatic cholelithiasis with possible choledocholithiasis. Endoscopy 38:779–786

    Article  PubMed  Google Scholar 

  12. Ammori BJ, Birbas K, Davides D, Vezakis A, Larvin M, McMahon MJ (2000) Routine vs “on demand” postoperative ERCP for small bile duct calculi detected at intraoperative cholangiography: clinical evaluation and cost analysis. Surg Endosc 14:1123–1126

    Article  CAS  PubMed  Google Scholar 

  13. Erickson RA, Carlson B (1995) The role of endoscopic retrograde cholangiopancreatography in patients with laparoscopic cholecystectomies. Gastroenterology 109:252–263

    Article  CAS  PubMed  Google Scholar 

  14. Sarli L, Costi R, Gobbi S, Iusco D, Sgobba G, Roncoroni L (2003) Scoring system to predict asymptomatic choledocholithiasis before laparoscopic cholecystectomy: a matched case-control study. Surg Endosc 17:1396–1403

    Article  CAS  PubMed  Google Scholar 

  15. Montariol T, Rey C, Charlier A, Marre P, Khabtani H, Hay JM, Fingerhut A, Lacaine F (1995) Preoperative evaluation of the probability of common bile duct stones. French Association for Surgical Research. J Am Coll Surg 180:293–296

    CAS  PubMed  Google Scholar 

  16. Menezes N, Marson LP, debeaux AC, Muir IM, Auld CD (2000) Prospective analysis of a scoring system to predict choledocholithiasis. Br J Surg 87:1176–1181

    Article  CAS  PubMed  Google Scholar 

  17. Topal B, Fieuws S, Tomczyk K, Aerts R, Van Steenbergen W, Verslype C, Penninckx F (2009) Clinical models are inaccurate in predicting bile duct stones in situ for patients with gallbladder. Surg Endosc 23:38–44

    Article  CAS  PubMed  Google Scholar 

  18. Berdah SV, Orsoni P, Bege T, Barthet M, Grimaud JC, Picaud R (2001) Follow-up of selective endoscopic ultrasonography and/or endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy: a prospective study of 300 patients. Endoscopy 33:216–220

    Article  CAS  PubMed  Google Scholar 

  19. Topal B, Van de Moortel M, Fieuws S, Vanbeckevoort D, Van Steenbergen W, Aerts R, Penninckx F (2003) The value of magnetic resonance cholangiopancreatography in predicting common bile duct stones in patients with gallstone disease. Br J Surg 90:42–47

    Article  CAS  PubMed  Google Scholar 

  20. Suc B, Escat J, Cherqui D, Fourtanier G, Hay JM, Fingerhut A, Millat B (1998) Surgery vs endoscopy as primary treatment in symptomatic patients with suspected common bile duct stones: a multicenter randomized trial. French Associations for Surgical Research. Arch Surg 133:702–708

    Article  CAS  PubMed  Google Scholar 

  21. Cuschieri A, Lezoche E, Morino M, Croce E, Lacy A, Toouli J, Faggioni A, Ribeiro VM, Jakimowicz J, Visa J, Hanna GB (1999) E.A.E.S. multicenter prospective randomized trial comparing two-stage vs single-stage management of patients with gallstone disease and ductal calculi. Surg Endosc 13:952–957

    Article  CAS  PubMed  Google Scholar 

  22. Russell I (1995) Evaluating new surgical procedures. BMJ 311:1243–1244

    CAS  PubMed  Google Scholar 

  23. Nathanson LK, O’Rourke NA, Martin IJ, Fielding GA, Cowen AE, Roberts RK, Kendall BJ, Kerlin P, Devereux BM (2005) Postoperative ERCP versus laparoscopic choledochotomy for clearance of selected bile duct calculi: a randomized trial. Ann Surg 242:188–192

    Article  PubMed  Google Scholar 

  24. Waage A, Strömberg C, Leijonmarck CE, Arvidsson D (2003) Long-term results from laparoscopic common bile duct exploration. Surg Endosc 17:1181–1185

    Article  CAS  PubMed  Google Scholar 

  25. Tranter SE, Thompson MH (2002) Comparison of endoscopic sphincterotomy and laparoscopic exploration of the common bile duct. Br J Surg 89:1495–1504

    Article  CAS  PubMed  Google Scholar 

  26. Bingener J, Schwesinger WH (2006) Management of common bile duct stones in a rural area of the United States: results of a survey. Surg Endosc 20:577–579

    Article  CAS  PubMed  Google Scholar 

  27. Poulose BK, Arbogast PG, Holzman MD (2006) National analysis of in-hospital resource utilization in choledocholithiasis management using propensity scores. Surg Endosc 20:186–190

    Article  CAS  PubMed  Google Scholar 

  28. Collins C, Maguire D, Ireland A, Fitzgerald E, O’Sullivan GC (2004) A prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of choledocholithiasis revisited. Ann Surg 239:28–33

    Article  PubMed  Google Scholar 

  29. Tranter SE, Thompson MH (2003) Spontaneous passage of bile duct stones: frequency of occurrence and relation to clinical presentation. Ann R Coll Surg Engl 85:174–177

    Article  CAS  PubMed  Google Scholar 

  30. Martin IJ, Bailey IS, Rhodes M, O’Rourke N, Nathanson L, Fielding G (1998) Towards T-tube free laparoscopic bile duct exploration: a methodologic evolution during 300 consecutive procedures. Ann Surg 228:29–34

    Article  CAS  PubMed  Google Scholar 

  31. Gurusamy KS, Samraj K (2007) Primary closure versus T-tube drainage after open common bile duct exploration. Cochrane Database Syst Rev (1):CD005640

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Acknowledgment

Native English speaker translation was performed by Kathleen Page Jones (email: 0521830398@iol.it).

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Authors and Affiliations

  1. Service de Chirurgie Viscérale Digestive et Urologique, Hôpital Victor Dupouy, Argenteuil, France

    Renato Costi, Christine Manceau, Bernard Vacher & Alain Valverde

  2. Dipartimento di Scienze Chirurgiche, Università degli Studi di Parma, Via Gramsci 14, 43100, Parma, Italy

    Renato Costi, Antonio Mazzeo & Francesco Tartamella

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  1. Renato Costi
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Correspondence to Renato Costi.

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Costi, R., Mazzeo, A., Tartamella, F. et al. Cholecystocholedocholithiasis: a case–control study comparing the short- and long-term outcomes for a “laparoscopy-first” attitude with the outcome for sequential treatment (systematic endoscopic sphincterotomy followed by laparoscopic cholecystectomy). Surg Endosc 24, 51–62 (2010). https://doi.org/10.1007/s00464-009-0511-6

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