Skip to main content

Advertisement

SpringerLink
Log in

Appropriate management of common bile duct stones: A RAND Corporation/UCLA Appropriateness Method statistical analysis

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

Bile duct stones affect 10% of patients who undergo a cholecystectomy and therefore represent a major health problem. Laparoscopic common bile duct exploration, endoscopic sphincterotomy, and open surgical choledocholithotomy are the three available methods for dealing with choledocholithiasis. Though many trials and reviews have compared all three strategies, a list of indications for defined patient profiles is lacking.

Methods

We employed the RAND Corporation/UCLA Appropriateness Method (RAM) to evaluate the three procedures for bile duct stone clearance. An expert panel judged appropriateness after a comprehensive bibliography review, a first-round private rating of 108 different clinical situations, a consensus meeting, and a second round of definitive rating. A list of indications for each procedure was statistically calculated.

Results

A consensus was reached for 41 indications (38%). The endoscopic approach was always appropriate for preoperatively diagnosed bile duct stones and inappropriate for patients with single intraoperative detected stones causing cholangitis and bile duct dilatation. Laparoscopic bile duct exploration was appropriate for preoperatively diagnosed choledocholithiasis if patients had not undergone a previous cholecystectomy and no signs of cholangitis were detected. The laparoscopic approach was also appropriate for intraoperatively incidentally detected stones, except for septic patients with poor performance status and multiple calculi. Laparoscopic bile duct clearance was judged inappropriate for septic patients with poor performance status and absence of bile duct dilatation. Open surgery was appropriate in all patients with intraoperative diagnosis of choledocholithiasis and cholangitis and in septic patients with bile duct dilatation. There was no clinical situation in which open surgery was appropriate when bile duct stones were preoperatively diagnosed.

Conclusions

There is still uncertainty with respect to the management of choledocholithiasis, showing the need for further investigation. The RAM helps to elucidate appropriateness for the different treatment options in specific clinical settings.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Petelin JB (2003) Laparoscopic common bile duct exploration. Surg Endosc 17:1705–1715

    Article  CAS  PubMed  Google Scholar 

  2. Santambrogio R, Bianchi P, Opocher E, Verga M, Montorsi M (1999) Prevalence and laparoscopic ultrasound patterns of choledocholithiasis and biliary sludge during cholecystectomy. Surg Laparosc Endosc Percutan Tech 9:129–134

    Article  CAS  PubMed  Google Scholar 

  3. 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 

  4. [No authors listed] (1993) Gallstones and laparoscopic cholecystectomy. NIH consensus development panel on gallstones and laparoscopic cholecystectomy. Surg Endosc 7:271-279

    Google Scholar 

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

  6. 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 

  7. 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 

  8. 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 

  9. Tinoco R, Tinoco A, El-Kadre L, Peres L, Sueth D (2008) Laparoscopic common bile duct exploration. Ann Surg 247:674–679

    Article  PubMed  Google Scholar 

  10. Uchiyama K, Onishi H, Tani M, Kinoshita H, Kawai M, Ueno M, Yamaue H (2003) Long-term prognosis after treatment of patients with choledocholithiasis. Ann Surg 238:97–102

    Article  PubMed  Google Scholar 

  11. Tanaka M, Takahata S, Konomi H, Matsunaga H, Yokohata K, Takeda T, Utsunomiya N, Ikeda S (1998) Long-term consequence of endoscopic sphincterotomy for bile duct stones. Gastrointest Endosc 48:465–469

    Article  CAS  PubMed  Google Scholar 

  12. Neuhaus H, Feussner H, Ungeheuer A, Hoffmann W, Siewert JR, Classen M (1992) Prospective evaluation of the use of endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy. Endoscopy 24:745–749

    Article  CAS  PubMed  Google Scholar 

  13. Vitale GC, Larson GM, Wieman TJ, Cheadle WG, Miller FB (1993) The use of ERCP in the management of common bile duct stones in patients undergoing laparoscopic cholecystectomy. Surg Endosc 7:9–11

    Article  CAS  PubMed  Google Scholar 

  14. Stromberg C, Luo J, Enochsson L, Arnelo U, Nilsson M (2008) Endoscopic sphincterotomy and risk of malignancy in the bile ducts, liver, and pancreas. Clin Gastroenterol Hepatol 6:1049–1053

    Article  PubMed  Google Scholar 

  15. Urbach DR, Khajanchee YS, Jobe BA, Standage BA, Hansen PD, Swanstrom LL (2001) Cost-effective management of common bile duct stones: a decision analysis of the use of endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography, and laparoscopic bile duct exploration. Surg Endosc 15:4–13

    Article  CAS  PubMed  Google Scholar 

  16. Griniatsos J, Karvounis E, Arbuckle J, Isla AM (2005) Cost-effective method for laparoscopic choledochotomy. ANZ J Surg 75:35–38

    Article  PubMed  Google Scholar 

  17. Poulose BK, Speroff T, Holzman MD (2007) Optimizing choledocholithiasis management: a cost-effectiveness analysis. Arch Surg 142:43–48; discussion 49

    Article  PubMed  Google Scholar 

  18. 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 

  19. Alhamdani A, Mahmud S, Jameel M, Baker A (2008) Primary closure of choledochotomy after emergency laparoscopic common bile duct exploration. Surg Endosc 22:2190–2195

    Article  PubMed  Google Scholar 

  20. Wills VL, Gibson K, Karihaloot C, Jorgensen JO (2002) Complications of biliary T-tubes after choledochotomy. ANZ J Surg 72:177–180

    Article  PubMed  Google Scholar 

  21. Campbell-Lloyd AJ, Martin DJ, Martin IJ (2008) Long-term outcomes after laparoscopic bile duct exploration: a 5-year follow up of 150 consecutive patients. ANZ J Surg 78:492–494

    Article  PubMed  Google Scholar 

  22. Waage A, Stromberg 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 

  23. Poston GJ, Adam R, Alberts S, Curley S, Figueras J, Haller D, Kunstlinger F, Mentha G, Nordlinger B, Patt Y, Primrose J, Roh M, Rougier P, Ruers T, Schmoll HJ, Valls C, Vauthey NJ, Cornelis M, Kahan JP (2005) OncoSurge: a strategy for improving resectability with curative intent in metastatic colorectal cancer. J Clin Oncol 23:7125–7134

    Article  PubMed  Google Scholar 

  24. Fink A, Kosecoff J, Chassin M, Brook RH (1984) Consensus methods: characteristics and guidelines for use. Am J Public Health 74:979–983

    Article  CAS  PubMed  Google Scholar 

  25. Wietlisbach V, Vader JP, Porchet F, Costanza MC, Burnand B (1999) Statistical approaches in the development of clinical practice guidelines from expert panels: the case of laminectomy in sciatica patients. Med Care 37:785–797

    Article  CAS  PubMed  Google Scholar 

  26. Park RE, Fink A, Brook RH, Chassin MR, Kahn KL, Merrick NJ, Kosecoff J, Solomon DH (1989) Physician ratings of appropriate indications for three procedures: theoretical indications vs indications used in practice. Am J Public Health 79:445–447

    Article  CAS  PubMed  Google Scholar 

  27. Linstone HA, Turoff M (1975) The Delphi method: techniques and applications. Addisson-Wesley, Reading, MA

    Google Scholar 

  28. Fitch K, Bernstein S, Aguilar MD, Burnand B, LaCalle JR, Lázaro P, van het Loo M, McDonnell J, Vader JP, Kahan JP (2001) The RAND/UCLA appropriateness user’s manual. RAND, MR-1269-DG XII/RESISTANCE, Santa Monica, CA

  29. Brook RH, Chassin MR, Fink A, Solomon DH, Kosecoff J, Park RE (1986) A method for the detailed assessment of the appropriateness of medical technologies. Int J Technol Assess Health Care 2:53–63

    Article  CAS  PubMed  Google Scholar 

  30. 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 

  31. Schwesinger WH, Sirinek KR, Strodel WE 3rd (1999) Laparoscopic cholecystectomy for biliary tract emergencies: state of the art. World J Surg 23:334–342

    Article  CAS  PubMed  Google Scholar 

  32. Verbesey JE, Birkett DH (2008) Common bile duct exploration for choledocholithiasis. Surg Clin North Am 88:1315–1328 ix

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

The present study was performed under the collaboration framework of the National Health System Quality Plan, the Carlos III Health Institute, and the Progress and Health Foundation of the Andalusian Government. Our thanks go to the members of the expert panel and the moderator of the second-round rating meeting: Dr. Salvador Rufian Peña (Hospital Reina Sofía, Cordoba, Spain), Dr. Rafael Bañares Cañizares (Hospital Universitario Gregorio Marañón, Madrid, Spain), Dr. Antonio Naranjo Rodriguez (Hospital Universitario Reina Sofía, Córdoba, Spain), Dr. Esteban Cugat Andorrá (Hospital de la Mutua de Terrasa, Barcelona, Spain), Dr. Juan Ruiz Castillo (Hospital Universitario San Cecilio, Granada, Spain), Dr. Julio Santoyo Santoyo (Hospital Carlos Haya, Málaga, Spain), Dr. Eduardo Targarona Soler (Hospital de la Santa Creu y San Pau, Barcelona, Spain), Dr. Antonio Torres García (Hospital Clínico San Carlos, Madrid, Spain).

Disclosures

Pablo Parra-Membrives, Daniel Díaz-Gómez, Román Vilegas-Portero, Máximo Molina-Linde, Lourdes Gómez-Bujedo, and Juan Ramón Lacalle-Remigio have no conflicts of interest or financial ties to disclose.

Author information

Authors and Affiliations

  1. Hepato-bilio-pancreatic Surgery Unit of the General and Digestive Surgery Department, Valme University Hospital, Carretera de Cádiz s/n, 41014, Sevilla, Spain

    Pablo Parra-Membrives & Daniel Díaz-Gómez

  2. Andalusian Agency for Health Technology Assessment, The Emerging Technologies Observatory, Sevilla, Spain

    Román Vilegas-Portero & Máximo Molina-Linde

  3. High Resolution Hospital Center of Utrera, Sevilla, Spain

    Lourdes Gómez-Bujedo

  4. Department of Preventive Medicine, University of Seville, Sevilla, Spain

    Juan Ramón Lacalle-Remigio

Authors
  1. Pablo Parra-Membrives
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Daniel Díaz-Gómez
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Román Vilegas-Portero
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Máximo Molina-Linde
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Lourdes Gómez-Bujedo
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Juan Ramón Lacalle-Remigio
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Pablo Parra-Membrives.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Parra-Membrives, P., Díaz-Gómez, D., Vilegas-Portero, R. et al. Appropriate management of common bile duct stones: A RAND Corporation/UCLA Appropriateness Method statistical analysis. Surg Endosc 24, 1187–1194 (2010). https://doi.org/10.1007/s00464-009-0748-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-009-0748-0

Keywords

Search

Navigation