Laparoscopic cholecystectomy and lithiasis of the common bile duct: prospective study on the importance of preoperative endoscopic ultrasonography and endoscopic retrograde cholangiography

OBJECTIVES: Laparoscopic cholecystectomy is the standard treatment of symptomatic gallstones. At present, no consensus has been reached on the diagnostic and therapeutic methods of concomitant common bile duct stones. Systematic preoperative endoscopic ultrasonography followed, if necessary, by endoscopic retrograde cholangiography and sphincterotomy during the same anesthetic procedure could be a diagnostic and therapeutic alternative for common bile duct stones making possible a laparoscopic cholecystectomy without intraoperative investigation of the common bile duct. METHODS: One hundred and twenty-five patients underwent a prospective endoscopic ultrasonographic evaluation prior to laparoscopic cholecystectomy for symptomatic gallstones. Fourty-four patients (35%) had at least one predictive factor for common bile duct stones. Endoscopic ultrasonography and cholecystectomy were performed on the same day. Endoscopic ultrasonography was followed by endoscopic retrograde cholangiography and sphincterotomy by the same endoscopist in case of common bile duct stones on endoscopic ultrasonography. Patients were routinely followed up between 3 and 6 months and one year after cholecystectomy. RESULTS: Endoscopic ultrasonography suggested common bile duct stones in 21 patients (17%). Endoscopic ultrasonography identified a stone in 17 of 44 patients (38.6%) with predictor of common bile duct stones and only in 4 of 81 patients (4.9%) without predictor of common bile duct stone. Among these 21 patients, one patient was not investigated with endoscopic retrograde cholangiography because of the high risk of sphincterotomy, 19 patients had a stone removed after sphincterotomy, one patient had no visible stone neither on endoscopic retrograde cholangiography, nor on exploration of the common bile duct after sphincterotomy. Endoscopic ultrasonography was normal in 104 patients (83%). However, two patients in this group were investigated with endoscopic retrograde cholangiography because endoscopic ultrasonography was incomplete in one case and because endoscopic ultrasonography was normal in the second case but a stone in the left hepatic duct was detected by ultrasonography. A stone was removed after endoscopic sphincterotomy in these two patients. In the group of 102 patients without stone, 91 out of 92, continued to be asymptomatic during a median follow-up of 8.5 months. One patient with symptoms one month after cholecystectomy underwent endoscopic sphincterotomy but no stone was found. CONCLUSIONS: Systematic preoperative endoscopic ultrasonography followed, if necessary with endoscopic retrograde cholangiography and sphincterotomy is a diagnostic and therapeutic alternative for common bile duct stones making possible a laparoscopic cholecystectomy without intraoperative investigation of the common bile duct for all patients. This alternative is only justifiable in patients with predictor of common bile duct stones.     

Laparo-endoscopic "rendezvous": a new technique in the choledocholithiasis treatment

BACKGROUND/AIMS: Endoscopic sphincterotomy for common bile duct stone clearance during laparoscopic cholecystectomy may fail due to difficulties in cannulating the papilla major. In this study we propose a new technique that facilitates the cannulation of the papilla and the common bile duct stone clearance during a standard laparoscopic cholecystectomy. Its clearance percentage, complication rate and post-operative stay have been evaluated and compared with standardized procedures such as open surgery and endoscopic sphincterotomy before laparoscopic cholecystectomy. METHODOLOGY: In a group of 16 patients presenting with cholelithiasis and common bile duct stones or papillitis, the sphincterotome was driven across the papilla into the choledochus by a Dormia basket passed in the duodenum through the cystic duct during laparoscopic cholecystectomy. Measures of outcome were clearance rate, mortality, morbidity and hospital stay. Furthermore, data obtained from this sample of patients were compared with those from another two groups of 16 patients in which choledocholithiasis was managed either by endoscopic sphincterotomy performed before laparoscopic cholecystectomy or by open cholecystectomy and trans-duodenal sphincterotomy. RESULTS: The rate of cannulation of the papilla and of the common bile duct stone clearance was 100% when the combined endo-laparoscopic approach was used in 15 patients with endoscopic sphincterotomy (93,7%) and in 15 patients with open sphincterotomy (93,7%), cholecystectomy was successful in every case. The groups were statistically similar with regard to complications; none of the patients required blood transfusion. The mean post operative stay was 95.2 hours (range 48-240) for the first group, 350.1 hours (range 192-1680) for the second and 69.7 hours (range 24-132) for the third. CONCLUSION: The laparo-endoscopic rendezvous, though still in evolution, is an efficacious method which can be used during the laparoscopic strategy of common bile duct clearance.     

Endoscopic papillotomy

Obstruction of the common bile duct can now be relieved by endoscopic electrosurgery. This report describes our experience with 267 patients. In 192 of 222 patients with choledocholithiasis all calculi were evacuated by endoscopic papillotomy (EP). The remaining patients had EP because of papillary stenosis. Complications of EP included nine instances of pancreatitis, seven of bleeding, and two perforations. In 2 of 32 patients having EP for papillary stenosis, restenosis has appeared on follow-up. The two fatalities were attributable to purulent cholangitis and acute bleeding. This required to manage these situations. The endoscopic method requires less hospitalization and recuperation. EP and stone extraction are the methods of choice for managing common duct obstruction in high risk patients before cholecystectomy, for retained or reformed stones after cholecystectomy, and for papillary stenosis.     

A prospective experience with selective cholangiography

A prospective study of patients with symptomatic cholelithiasis was undertaken to determine the effectiveness of identifying clinically significant choledocholithiasis with selective cholangiography. Between 1991 and 1995, 262 patients presented to the senior author (K.W.M.) with acute or chronic cholecystitis. Sixteen patients had a preoperative endoscopic retrograde cholangiopancreatography (ERCP) for an elevated alkaline phosphatase or total bilirubin greater than twice the normal value or an ultrasound finding suspecting choledocholithiasis. Ten of the ERCP patients had choledocholithiasis, with eight patients having successful clearance by ERCP. Ninety other patients had intraoperative cholangiography for abnormal serum liver biochemistries, a history of jaundice or pancreatitis, or a dilated common bile duct (CBD) (>6 mm) on ultrasound. Fourteen of the intraoperative cholangiography patients and the two remaining ERCP patients had choledocholithiasis requiring CBD exploration for clearance of their stones. There were no false-positive cholangiograms, and there were no bile duct injuries in this series. With 100 per cent follow-up of at least 2 years, only one patient required ERCP clearance of a retained CBD stone 13 months after cholecystectomy. The positive predictive value and the negative predictive value for the selective cholangiography criteria are 23 per cent and 99 per cent, respectively. In conclusion, clinically significant choledocholithiasis can be found effectively with selective cholangiography. Also, utilizing selective cholangiography reduces the number of routine cholangiograms by 60 per cent.     

Endoscopic bile duct stone removal prior to laparoscopic cholecystectomy

Of 1049 patients referred for laparoscopic cholecystectomy (LC) for symptomatic gallstone disease, 67 (6%) had clinical, biochemical, or echographic findings suggesting common bile duct stones. Patients in this group were studied preoperatively with endoscopic retrograde cholangiopancreatography (ERCP). In 26 patients (39%), the diagnosis was confirmed. In 12 other cases (18%), the macroscopic finding of a stripped or bleeding papilla without common bile duct stones suggested stone migration. ERCP in the remaining 29 patients (43%) was normal. Thirty-four endoscopic sphincterotomies (ES) were performed, 26 for common bile duct stones and 8 for cystic lithiasis or gallbladder microlithiasis. In the entire group of patients with choledocholithiasis, stone removal was possible. All 67 patients underwent laparoscopic cholecystectomy on an average of 2.8 days following the endoscopic procedure. Twenty-one patients (31%) had acute cholecystitis, and 5 had chronic scleroatrophic cholecystitis. Five (7.5%) of the 67 patients were converted to an open procedure. In 10 cases (16%), the cystic diameter was larger than an 8-mm M-L clip, which made necessary the use of endoligature or extra clips. No complications or deaths resulted from ERCP or ES. Two of the 62 patients (3.2%) who underwent LC had to be reoperated on, 1 because of a right subphrenic collection, and the other because of bilious ascites. No common bile duct lesions or deaths resulted in the analyzed group. The average hospitalization time, with the exception of those patients converted or reoperated on, was 8 days.     

Combined laparoscopic and endoscopic management of cholelithiasis and choledocholithiasis

With the advent of laparoscopic cholecystectomy, optimal management of common duct stones remains controversial. Seven hundred six patients underwent laparoscopic cholecystectomy in our institution from January 1990 through January 1992. From this group of patients, 50 were identified as having clinical or radiographic evidence of common duct stones. Thirty-one patients demonstrated preoperative risk factors for common duct stones and underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP). The risk factors included jaundice (19%), pancreatitis (23%), elevated liver function tests (52%), and ultrasound evidence of choledocholithiasis (6%). Preoperative ERCP was performed in 94% of patients. There were two failures due to periampullary diverticula. Common duct stones were identified in 18 patients (62%) and successfully removed by endoscopic sphincterotomy in all of these patients. Nineteen patients were found to have unsuspected common duct stones on intraoperative cholangiography. Eighteen patients (95%) underwent successful ERCP and endoscopic sphincterotomy with stone extraction. Overall, major morbidity was 2% and included one patient who experienced endoscopic sphincteroplasty. The three endoscopic failures were managed by open common duct exploration, laparoscopic duct exploration, and combined laparoscopic and open common duct exploration. We conclude that combined laparoscopic and endoscopic therapy is a viable option for the management of cholelithiasis with choledocholithiasis.     

Selected versus routine use of intraoperative cholangiography during laparoscopic cholecystectomy

Routine use of intraoperative cholangiography during laparoscopic cholecystectomy is still widely advocated and standard in many departments, however, this is discussed controversially. We have developed a new diagnostic strategy to detect bile duct stones. The concept is based on an ultrasound examination and on a screening for the presence of six risk indicators of choledocholithiasis. 120 consecutive patients undergoing laparoscopic cholecystectomy were prospectively screened for the presence of six risk indicators of choledocholithiasis: history of jaundice; history of pancreatitis; hyperbilirubinemia; hyperamylasemia; dilated bile duct; unclear ultrasound findings. The sensitivity of ultrasound and of intraoperative cholangiography in diagnosing bile duct stones was also evaluated. For the detection of bile duct stones, the sensitivity was 77% for ultrasound and 100% for intraoperative cholangiography. 20% of all patients had at least one risk indicator. The presence of a risk indicator correlated significantly with the presence of choledocholithiasis (p < 0.01, chi-square-test). The negative predictive value of the total set of risk indicators was 100%. Following our diagnostic concept, we would have avoided 80% of intraoperative cholangiographies without missing a stone in the bile duct. This study lends further support to the view that the routine use of intraoperative cholangiography in patients undergoing laparoscopic cholecystectomy is not necessary.     

15 years of endoscopic therapy in choledocholithiasis

INTRODUCTION: The relevance of endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and treatment of common bile duct stones has increased since the introduction of laparoscopic cholecystectomy in 1989-1990. METHODS: The number, indications, success and complication rate of ERCP were analyzed retrospectively in 1121 consecutive patients with bile duct stones treated at Berne University Hospital between 1980 and 1994. RESULTS: The number of patients undergoing endoscopic stone extraction increased slowly from 1980 to 1990, but has shown a 4-fold increase in the last 5 years parallel to the introduction of laparoscopic cholecystectomy. Failure to diagnose and remove bile duct stones decreased 5-fold from 23% (14 of 60 patients) in 1986 to 4.4% (10 of 225 patients) in 1994. Major complications occurred in 3.2% (30 of 617 patients) and consisted of acute pancreatitis (1.6%), hemorrhage of the papilla (1%), and cholangitis (0.6%). The severity but not the number of complications has decreased in the last 15 years. CONCLUSION: Gallbladder stones with common bile duct stones are usually treated by endoscopic stone extraction combined with laparoscopic cholecystectomy. Open operation with bile duct exploration is reserved for a small subgroup of patients with specific problems.     

Sulbactam/ampicillin in comparison with cefuroxime for infections of the lower respiratory tract. Results of a prospective, randomized comparative study

Gallbladder removal using laparoscopic techniques has rapidly been adopted by surgeons around the world. Questions have been raised concerning laparoscopic cholecystectomy, including the safety of the operation, its implications for management of common bile duct stones, and the means by which surgeons should be trained. In the present series, 424 patients were referred to a single surgeon for cholecystectomy during a 22-month period. A traditional open cholecystectomy was performed in 9 patients (2.1%) because of presumed contraindications to laparoscopic cholecystectomy. Laparoscopic cholecystectomy was attempted in the remaining 415 patients (97.9%). On the basis of preoperative investigations, 19 patients (4.6%) underwent endoscopic retrograde cholangiopancreatography. Endoscopic sphincterotomy and stone extraction were performed in the 13 patients (3.1%) demonstrating choledocholithiasis. Laparoscopic cholecystectomy was converted to an open operation in 8 patients (1.9%) owing to dense adhesions, obscure anatomy, or cholangiographic abnormalities. Laparoscopic cholecystectomy was successfully performed in 407 patients (96%) in 95 +/- 2 minutes (mean +/- SEM). Surgical trainees were involved in all operations and performed 68% of the procedures under supervision. Cystic duct cholangiograms were obtained selectively in 129 patients (30.4%). Intraoperative complications occurred in 3 patients, including 1 patient with a minor injury to the common bile duct (0.2%). There was no perioperative mortality, and major complications occurred in 6 patients (1.4%). Minor complications were seen in 12 others (2.8%), and one patient required reoperation for a trocar injury to the jejunum. Prolonged follow-up has revealed one case of asymptomatic retained common bile duct stones (0.2%). Laparoscopic cholecystectomy can therefore be performed in more than 95% of patients with no mortality and minimal morbidity.(ABSTRACT TRUNCATED AT 250 WORDS)     

Management of choledocholithiasis in patients undergoing laparoscopic cholecystectomy

The development of laparoscopic cholecystectomy has rekindled the issue of management of choledocholithiasis. A number of options exist including pre or postoperative endoscopic sphincterotomy (ERCP-ES), laparoscopic common duct exploration or open common duct exploration. We present here our experience with the management of choledocholithiasis in patients treated with laparoscopic cholecystectomy. From January 1991 to January 1995, 900 patients underwent laparoscopic cholecystectomy. 71 ERCP were carried out in 71 patients with suspicion or evidence of choledocholithiasis. Common duct stones were detected in 44 patients. Preoperative ERCP was done in 56 patients, with suspicion of choledocholithiasis, based on clinical, laboratory or ultrasonographic findings. 29 of these patients (51.7%) had common duct stones, that were successfully removed by endoscopic sphincterotomy. One patient suffered mild pancreatitis and a second one had transient hyperamylasemia. Postoperative ERCP was performed in 15 patients. Indications for ERCP were the evidence of common duct stones in intraoperative cholangiography in 7 cases, and clinical or laboratory suspicion of choledocholithiasis, 3 months to 3 years after laparoscopic cholecystectomy. Stones were detected in 100% of the patients. In 11 patients (73.3%), the stones were extracted by endoscopic sphincterotomy and 4 patients underwent open common duct exploration. Two patients had transient hyperamylasemia. ERCP is a safe and effective method for detection and treatment of common duct stones. ERCP prior to laparoscopic cholecystectomy in patients suspected of having choledocholithiasis, is safe and offers with good results. Rutinary intraoperative cholangiography is recommended, for the detection of unsuspected choledocholithiasis and as an effective treatment (postoperative-ERCP, open or laparoscopic common duct exploration) can be chosen depending on surgeon's skills and patient's characteristics.     

Intraoperative cholangiography as a routine method? A prospective, controlled, randomized study

A prospective, controlled, randomized trial was conducted in 275 patients with symptomatic gall stone disease, whose history, laboratory data or sonographical findings did not suggest common bile duct stones. Of these patients, 137 did not undergo intraoperative fluoroscopic cholangiography (IOC), but in the remaining 138 patients IOC was attempted. In 111 cases (80.4%) the biliary system was sufficiently visualized. In 3 patients (2.7%) calculi in the cystic or common bile duct were diagnosed, which would have been overlooked without IOC. IOC was false-positive in one case. One year after the operation the patients were asked to return for a follow-up examination. Three patients in the group without IOC had had symptomatic passage of a stone, and one had a common bile duct stone removed by endoscopic papillotomy. A retained stone was discussed as etiology for a pancreatitis in a fifth patient in this group. No patient sustained long-term sequelae from the retained common bile duct stones. None of the patients in the IOC group had evidence of cholangiolithiasis at follow-up. There was no difference between the study groups concerning the incidence of post-operative complications. The operations with IOC lasted significantly longer (92 +/- 31 min vs 77 +/- 28 min). According to our data and those published earlier, the additional financial and logistic expenditure associated with routine IOC is not justified. Patients with the preoperative suspicion of a common bile duct stone should have endoscopic bile duct clearance (ERCP and EPT) prior to cholecystectomy.     

Psychopathology as adaptive development along distinctive pathways

The vast majority of post-operative bile duct strictures occur following cholecystectomy, these injuries having been seen at an increased frequency since the introduction of laparoscopic cholecystectomy. Bile duct injuries usually present early in the post-operative period, obstructive jaundice or evidence of a bile leak being the most common mode of presentation. In patients presenting with a post-operative bile duct stricture months to years after surgery, cholangitis is the most common symptom. The 'gold standard' for the diagnosis of bile duct strictures is cholangiography. Percutaneous transhepatic cholangiography is generally more valuable than endoscopic retrograde cholangiography in that it defines the anatomy of the proximal biliary tree that is to be used in surgical reconstruction. The most commonly employed surgical procedure with the best overall results for the treatment of bile duct stricture is a Roux-en-Y hepaticojejunostomy. The results of the surgical repair of bile duct strictures are excellent, long-term success rates being in excess of 80% in most series. Recent data have suggested that, at intermediate follow-up of approximately 3 years, an excellent outcome can be obtained following repair of bile duct injuries after laparoscopic cholecystectomy. Percutaneous and endoscopic techniques for the dilatation of bile duct strictures can be useful adjuncts to the management of bile duct strictures if the anatomical situation and clinical scenario favour this approach. In selected patients, the results of both endoscopic and percutaneous dilatation are comparable to those of surgical reconstruction.     

Drug efflux as a mechanism of resistance

The rate of iatrogenic bile duct lesions has raised up to 3.5% after the introduction of laparoscopic cholecystectomy. Lesions that can not be managed endoscopically require surgical intervention. In this study 12 patients that presented with iatrogenic bile duct lesions following laparoscopic cholecystectomy and underwent reconstructive surgery at our institution are included. In nine patients a hepaticojejunostomy was performed, whereas two patients underwent end-to-end anastomosis. In one patient the lesion was oversewn. There were no complications postoperatively. After a median follow-up of 24,5 months (SD +/- 8 months) all patients are without symptoms. However, in two patients a postoperative endoscopic stenting for 4 months was necessary for bouginage. Reconstructive surgery, mainly hepaticojejunostomy in bile duct lesions is a safe and efficacious treatment of endoscopic treatment failure.     

Endoscopic sphincterotomy in choledocholithiasis and an intact gallbladder

Endoscopic sphincterotomy (ES) with extraction of calculi is a basic method of treating choledocholithiasis in post-cholecystectomy patients (8, 9). Endoscopic treatment contributes to a considerable reduction of the indications for reoperation. The existing views concerning ES done in patients with preserved gallbladder, especially in the era of laparoscopic surgery, are still conflicting (3, 6). There are several options: cholecystectomy with removal of calculi in the common bile duct by ES in a subsequent stage, or vice versa-primary ES with ensuring cholecystectomy. The undertaking of independent surgical or endoscopic treatment is likewise practicable (2, 6).     

Endoscopic papillotomy (EPT) with removal of common bile duct stones

Endoscopic papillotomy with removal of common bile duct stones was successfully performed in 14 patients. In 11 patients stones were found after cholecystectomy. In the remaining 3 patients there was a high operative risk. No serious complications occurred. Consequently the removal of choledocholithiasis by endoscopic papillotomy is an alternative to traditional treatment.     

Simultaneous laparoscopic therapy of cholecysto- and choledocholithiasis. An analysis of results

INTRODUCTION: With the advent of laparoscopic cholecystectomy, ERCP has gained importance in the treatment of choledocholithiasis. Laparoscopic cholecystectomy with intraoperative cholangiography and common bile duct surgery allows diagnosis and treatment of cholecystolithiasis and choledocholithiasis in a single procedure. PATIENTS AND METHODS: Laparoscopic treatment of choledocholithiasis was evaluated in 99 consecutive patients with choledocholithiasis. 28 patients underwent successful preoperative ERCP. Of the patients with intraoperative confirmation of choledocholithiasis, removal was attempted by a transcystic approach in 36 and 23 underwent choledochotomy. 24 patients with a high operative risk underwent postoperative ERCP. RESULTS: The transcystic approach was successful in 72.2%. Choledochotomy was successful in 91.3%, yielding a combined success rate of 80%, 3.4% had local complications and 8.4% had other complications (complication rate 11.8%), 20.3% of the patients underwent ERCP after failed laparoscopic procedures. One patient had a laparoscopic redo. There was no mortality and no conversion to open surgery. CONCLUSION: ERCP and laparoscopic common bile duct surgery are complementary, efficient and safe modalities of treatment for choledocholithiasis. Choice of procedure is influenced by the surgeon's experience and institutional infrastructure, and the individual patient.     

Bile duct injury following laparoscopic cholecystectomy: referral pattern and management

BACKGROUND: Laparoscopic cholecystectomy is associated with a higher incidence of bile duct injury than open cholecystectomy. This study reviews the management of bile duct injury in a tertiary hepatobiliary unit. METHODS: From 1991 to 1995, 27 patients (18 women) of median age 49 (range 25-67) years were referred to this unit with bile duct injury following elective laparoscopic cholecystectomy. Laparoscopic cholecystectomy was described as 'uneventful' in 14 and 'difficult' in 13 patients; six injuries were recognized at operation. RESULTS: Patients were transferred a median of 26 (range 0-990) days after laparoscopic cholecystectomy, although initial symptoms were recorded a median of 3 (range 0-700) days after cholecystectomy. Fifteen patients underwent additional surgery before referral. Management before referral included surgical exploration (15 patients), endoscopic cholangiography (ERC) and stent insertion (three), external drainage of bile collections (five), and conservative management (five). Management after referral included surgical reconstruction (19 patients), laparotomy with drainage (one), percutaneous drainage (two), ERC and stent insertion (two), percutaneous cholangiography with dilatation and stent placement (three), and conservative management (two). One patient died and the median inpatient stay following referral was 14 (range 7-78) days. Ten of 15 patients who had surgery before referral required a further biliary reconstruction. After median follow-up of 30 (range 3-60) months, four of nine patients with complex high injuries continue to have episodes of cholangitis and one patient has developed secondary biliary cirrhosis. CONCLUSION: Bile duct injury following laparoscopic cholecystectomy is a complex management problem and results in significant postoperative morbidity. Most patients referred after attempted repair require further reconstructive surgery, and patients with complex high injuries have a risk of long-term morbidity.     

Long-term follow-up of a prospective randomized study of endoscopic versus surgical treatment of bile duct calculi in patients with gallbladder in situ

Eighty-three patients with bile duct calculi were entered in a prospective randomized study of endoscopic sphincterotomy (ES) and stone removal (group 1) versus surgery alone (group 2), and were followed for more than 5 years. In group 1 endoscopic stone clearance was successful in 35 of 39 patients. Thirteen patients subsequently had cholecystectomy with (n = 7) or without (n = 6) biliary symptoms and one had a cholecystostomy for acute cholecystitis. Two patients have had mild biliary colic or pancreatitis. Two patients died from gallbladder carcinoma after 9 days and 18 months. In group 2 bile duct stones were cleared surgically in 37 of 41 patients. Late complications occurred in two patients (incisional hernia and recurrent stone). One patient with gallbladder carcinoma was cured and another died after 16 months. Early major and minor complications occurred in three and four respectively of 39 patients in group 1, and in three and six respectively of 41 patients in group 2. There were no deaths. During follow-up the total morbidity rate reached 28 percent (11 of 39) and 5 percent (two of 41) (P = 0.005) and the non-biliary related mortality rate was 31 percent (12 of 39) and 10 percent (four of 41) (P = 0.02) in groups 1 and 2 respectively. Nine patients in group 1 and two in group 2 died from heart disease (P = 0.02). Total hospital stay was 2-42 (median 13) days and 6-36 (median 16) days in groups 1 and 2 respectively (P not significant). Endoscopic and surgical treatment of bile duct calculi in middle-aged and elderly patients with gallbladder in situ are equally effective in the long term. However, the significantly increased mortality rate from heart disease in patients treated endoscopically compared with those treated surgically might speak in favour of operation.     

Urgent ERCP and early elective laparoscopic cholecystectomy in biliary pancreatitis

BACKGROUND: For many years the best algorithm of treatment for complicated gallstone disease has been intensively discussed. Gallstone pancreatitis with cholangitis still belongs to the most often identified causes of death of necrotizing pancreatitis. The reduction of complication and lethality rates was mainly achieved by urgent ERCP and sequential cholecystectomy. In a prospective study we have combined endoscopic therapy with laparoscopic cholecystectomy (LC) and are discussing the results. PATIENTS AND METHODS: Between May 1991 and December 1996 146 patients with biliary pancreatitis were subjected to ERCP after laboratory tests and ultrasound screening of the biliary system. If there were no contraindications and the gallbladder was still in situ, LC was attempted during the initial admission. RESULTS: Of the 70 patients with attempted LC 26 had common bile duct calculi, 23 had an impacted papillary stone and 10 had signs of a stone passage. 59 patients underwent LC successfully, a conversion to open surgery was necessary in 11 patients. The morbidity rate amounted to 7%, lethality to 0%. DISCUSSION: Since a more liberal indication for ERCP in the management of acute pancreatitis was introduced the number of biliary related cases of acute pancreatitis is increasing. In response to early endoscopic bile duct clearance the rates of morbidity and mortality can be significantly reduced. Early LC is the ideal complementary treatment option to absolutely prevent recurrencies.     

Introduction to instrument development: scaling methods

Endoscopic removal of biliary calculi is a safe and effective alternative to surgical exploration of the common bile duct. However, as stones increase in diameter, endoscopic retrieval becomes more difficult and hazardous. Mechanical lithotripsy is an endoscopic technique used to crush common bile duct stones that are too large to be removed by conventional methods. In the 3 years following the introduction of this technique at our institution, 145 patients underwent endoscopic retrograde cholangiopancreatography for symptomatic choledocholithiasis. Endoscopic mechanical lithotripsy improved the overall success rate of common bile duct clearance from 86.2% to 94.5%. No morbidity or mortality was associated with the procedure. Therefore, we recommend mechanical lithotripsy when bile duct stones cannot be removed with conventional techniques.