Editorial - Laparoscopic bile duct surgery: Home truths
Alfred Cuschieri2007
visibility
…
description
2 pages
link
1 file
Related papers
The role of choledochoscopy in transductal laparoscopic common bile duct exploration
General Surgery, 2021
Laparoscopic common bile duct exploration (LCBDE) performed by choledochoscope through the cystic duct or directly through the incision in the common bile duct (CBD) are well established methods for restoring biliary drainage function in patients with choledocholithiasis. Although it plays a crucial role in the transcystic approach, transductal approach can be achieved differently. However, it has restrictions in availability due to its expensiveness. Objective — to report efficacy of transductal LCBDE without laparoscopic choledochoscopy. Materials and methods. This is a prospective study of urgently admitted patients who underwent trans‑ductal LCBDE due to confirmed choledocholithiasis. During laparoscopy, clearance of the CBD was achieved in two ways: by choledochoscopy (group CS+, n = 43) and without it (group CS–, n = 34). The data of patient demographics, comorbidities, operative outcomes, morbidity, mortality and long‑term biliary complications were analysed and compared betw...
Laparoscopic Common Bile Duct Exploration: Our First 50 Cases
Annals Academy of Medicine Singapore, 2010
Introduction: Laparoscopic common bile duct exploration (CBDE) is becoming more popular in the management of choledocholithiasis due to improved laparoscopic expertise and advancement in endoscopic technology and equipment. This study aimed to evaluate the safety and short-term outcome of laparoscopic CBDE in a single institution over a 3-year period. Materials and Methods: A retrospective review of the records of all patients who underwent laparoscopic CBDE in Tan Tock Seng Hospital between January 2006 and September 2008 was conducted. Results: Fifty consecutive patients, with a median age of 60 years (range, 27 to 85) underwent laparoscopic CBDE for choledocholithiasis during the study period. About half of our patients presented as an emergency with acute cholangitis (32.0%) accounting for the majority. A total of 22 (44.0%) patients underwent laparoscopic CBDE as their primary procedure while the remaining 28 (56.0%) were subjected to preoperative ERCP initially. Of the latter group, documented stone clearance was only documented in 5 (17.9%) patients. Laparoscopic CBDE via the transcystic route was performed in 27 (54.0%) patients while another 18 patients (36.0%) had laparoscopic choledochotomy and 1 patient (2.0%) had laparoscopic choledocho-duodenostomy. There were 4 (8.0%) conversions in our series. The median operative time for laparoscopic CBDE via the transcystic route and the laparoscopic choledochotomy were 170 (75-465) and 250 (160-415) minutes, respectively. For the 18 patients who underwent a laparoscopic choledochotomy, Ttube was inserted in 8 (44.4%) patients while an internal biliary stent was placed in 4 (22.2%) with the remaining 6 patients (33.3%) undergoing primary closure of the choledochotomy. The median length of hospital stay was 2 days (range, 1 to 15) with no associated mortality. The main complications (n = 4, 8.0%) included retained CBD stones and biliary leakage. These were treated successfully with postoperative endoscopic retrograde cholangiopancreatography (ERCP) with/without percutaneous drainage with no further surgery required. Conclusion: Laparoscopic CBDE is a safe operation with good outcome in managing choledocholithasis. Its dividends include the numerous benefi ts of minimally invasive surgery. If possible, transcystic extraction is preferred to choledochotomy, as this obviates the need for biliary diversion. ERCP will still hold an important role in certain instances in the management of choledocholithiasis.
Common bile duct calculi--ERCP vs laparoscopic exploration: the case for endoscopic retrograde cholangiopancreatography (ERCP)
Annals of the Royal College of Surgeons of England, 2004
T he technique of endoscopic biliary sphincterotomy was first reported in 1974 1 and has become the accepted method for management of retained or recurrent bile duct stones. This is particularly applicable to frail and elderly patients who are poor surgical candidates. Since the late 1970s, numerous reports within the literature advocated that endoscopic retrograde cholangiopancreatography (ERCP) was more appropriate for the elderly where avoidance of general anaesthesia and laparotomy is desirable -reflected in high mortality rates for the open surgical approach. Over the last two decades, there have been several advances within the surgical domain. It has long been recognised that open cholecystectomy and bile duct clearance with 'T' tube placement is associated with a high morbidity and mortality rateparticularly in the elderly. This has largely been superseded by laparoscopic cholecystectomy and, in some centres, with laparoscopic bile duct exploration. Reported mortality for open surgical common bile duct exploration range from 5.5-12.8% in patients over the age of 60 years, 2,3 and as high as 29% in a British series of patients over the age of 70 years. 4 Despite the criticism that the initial data from Vellacott and Powell 4 arose from inexperienced surgical technique, more recent data still show a high mortality and morbidity in the elderly population. 5 In comparison, mortality rates related to ERCP and sphincterotomy are much lower being between 0-2.3%. 6
Laparoscopic common bile duct exploration: the past, the present, and the future.
BACKGROUND: The advent of laparoscopic cholecystectomy (LC) has created a dilemma for treating patients with known or suspected choledocholithiasis. With rapid technologic growth and experience in laparoscopic skills, many surgeons are now routinely performing laparoscopic common bile duct exploration (LCBDE) and questioning the wisdom of preoperative endoscopic retrograde cholangiography (ERC) with or without endoscopic sphincterotomy. The purpose of this article is to review the current literature on the subject of LCBDE and critically evaluate the clinical results of this emerging technology. METHODS: Medline and Science Citation Index databases were used to search English language articles published on LCBDE since 1989. RESULTS: Transcystic common bile duct exploration has a better clearance rate, and carries less morbidity and mortality compared with laparoscopic choledochotomy. Compared with two-stage ERCP and LC, one-stage LC and LCBDE seems to be associated with a shorter hospital stay, a quicker recovery, less expense, and less morbidity and mortality. CONCLUSIONS: LCBDE is a feasible, safe and effective procedure that carries a low morbidity and mortality and will decrease the need for unnecessary ERC in the future for suspected or proved choledocholithiasis.
A 23 year experience with laparoscopic common bile duct exploration
HPB : the official journal of the International Hepato Pancreato Biliary Association, 2017
Laparoscopic common bile duct exploration (LCBDE) during laparoscopic cholecystectomy (LC) is as effective as two-stage endo-laparoscopic treatment, but with shorter hospital stay, lower cost and recurrent stone rate. Aim of this paper was to report the authors' experience with LCBDE during LC. A retrospective analysis of patients who underwent LCBDE for ductal stones was performed. Recurrent stones were defined as CBD stones detected beyond 6 months from the procedure. Postoperative biliary stricture was defined as a symptomatic reduction of CBD diameter. Out of 3444 patients who underwent LC, 384 (11%) had CBD stones treated by trans-cystic duct exploration [214 (6%) patients, TCD-CBDE] or choledochotomy [170 (5%) patients, C-CBDE]. For TCD-CBDE and C-CBDE, mean operative time was 127 ± 69 and 191 ± 74 min, respectively. Major morbidity rate was 3% (n = 6) in TCD-CBDE and 6% (n = 11) in C-CBDE. The incidence of residual stones was 5% (n = 20) and complete ductal clearance rate...
Laparoscopic common bile duct exploration, does real life practice mirror the evidence?
Laparoscopic Surgery
Clinical evaluation of laparoscopic exploration of the common bile duct
Ain Shams Journal of Surgery, 2009
The management of CBD stones has traditionally required open laparotomy and bile duct exploration. Since the introduction of endoscopic retrograde cholangiopancreatography (ERCP), preoperative clearance of common bile duct (CBD) stones prior to cholecystectomy has been widely adopted. 1 However, in the present laparoscopic era, the best treatment for patients with choledocholithiasis is a matter of debate and the management of choledocholithiasis continues to evolve. If the stones are found by intraoperative cholangiography during laparoscopic cholecystectomy(LC), the surgeon may either do the LC and refer the patient to endoscopic sphincterotomy(ES) postoperatively,or he may convert to open CBD exploration or in the current times he may do laparoscopic CBD exploration (LCBDE). 2
Preliminary experience with laparoscopic common bile duct exploration
BMC Surgery, 2017
Background: Herein we present our experience with laparoscopic common bile duct exploration (LCBDE) in managing common bile duct stones. Methods: Data of 129 consecutive patients who underwent laparoscopic cholecystectomy (LC) and LCBDE done at our institutes from April 2011 through June 2016 were prospectively recorded and retrospectively reviewed. Results: Since 2011, 3012 laparoscopic cholecystectomy were performed at our institutes, intraoperative cholangiogram (IOC) was done in 295 (9.8%) patients which detected choledocholithiasis in 129 (4.3%) of them. LCBDE was successful to clear the common bile duct (CBD) in 123/129 (95.4%). Six patients underwent postoperative endoscopic retrograde cholangiopancreatography (ERCP) because of incomplete CBD clearance (4 cases), symptomatic stenosed papilla (2 cases). LCBDE was performed in 103 patients via trans-cystic approach and choledochotomy one in 26 patients. In the choledochotomy group, seven patients had primary closure of the CBD, CBD was closed over T-tube in nine patients whereas the remaining 10 patients the CBD was closed over antegrade inserted stent. The median time of hospital stay was 4 (range; 1-15) days. No patients showed retained CBD stones with mean follow up was 9 ± 3.4 months. Conclusion: LCBDE is a safe and cost effective option for CBD stones in short-term outcome and can be performed provided proper laparoscopic expertise and facilities are available.
Gregory E. Lamb, Living and Dying Well in Philippians: A Comparative Analysis of Ancient Sources, WUNT II (Tübingen: Mohr Siebeck, 2025)
WUNT II, 2025
The contemporary bifurcation of living and dying and the aversion of death are largely absent in ancient conceptions of human flourishing. Gregory Lamb bridges this gap by combining living and dying well as the twin facets of flourishing and by comparing the often-competing conceptions of flourishing within salient ancient sources (up to 100 CE). Beginning with Paul's concept of flourishing in Philippians, and then comparing/contrasting popular Greco-Roman, Egyptian, and Second Temple Jewish views, the volume advocates a »kaleidoscopic« reading of Paul that attunes to the complex diversity and Sitze im Leben of the Philippians. The author argues that Philippians is central to Paul's presentation of flourishing as a Christocentric, cruciform life, and that despite the competing conceptions of living and dying well in the cultures around him, Paul, nonetheless, stands in stark contrast to them. Table of contents: Chapter 1: Human Flourishing as a Subject of Pauline Research A. Kaleidoscopic Scope and Relevance for Biblical Studies B. Review of Literature C. Lacunae within the Current State of Research D. Overview of the Study Chapter 2: Comparative Methodology A. Comparative Analysis and Philippians B. Criteria for the Selection of Sources Chapter 3: Living and Dying Well in Philippians A. Flourishing as a Foundational Subtext B. Exegetical Analysis Chapter 4: Living and Dying Well in Greco-Roman, Egyptian, and Second Temple Jewish Sources A. Variegated Voices on Living and Dying Well B. Survey of Selected Sources Chapter 5: Comparative Analysis of Flourishing between Philippians and Ancient Sources A. Paul's Christocentric Reappropriation and »Answerability« B. Synthesis of the Comparative Data C. Areas for Further Research D. Concluding Reflections
Editorial
Laparoscopic bile duct surgery: Home truths
Alfred Cuschieri
Division of Medical Sciences, Scuola Superiore Sant'Anna di Studi Universitari Pisa, Italy
Address for correspondence: Alfred Cuschieri, Scuola Superiore Sant'Anna di Studi Universitari Pisa, Italy. E-mail: [email protected]
In this issue of JMAS, the article by Bandyopadhyay,
et al. on ‘Antegrade common bile duct (CBD) stenting
after laparoscopic CBD exploration’ [1] makes
interesting reading in addition to raising certain
unsettled issues concerning this laparoscopic
procedure. In the first instance, the authors are to be
complemented for the excellent clinical outcome of
their patients treated for ductal calculi with no
mortality and a morbidity approximating 6%, which
is well below that reported in most published series.
Another aspect of the series, which is most interesting
is the low negative endoscopic retrograde
cholangiopancreatography (ERCP) rate, 16/316
patients (5%) contrasting with the reported negative
rates varying from 20 to 50%. It is obvious that the
authors have very effective protocols for the selection
of patients requiring ERCP.
which are raised by the present publication in JMAS.
The important issues regarding the laparoscopic
surgical management of ductal calculi include: (i)
technique of ductal clearance, (ii) need for drainage of
CBD and if so, the best method to achieve this, and
(iii) indications for internal bilio-enteric drainage
(choledochoduodenostomy/choledochojejunostomy).
m
o
fr
d s
a
o ion
l
n OFat L APAROSCOPIC DUCTAL
TECHNIQUES
w
CLEARANCE
o blic
d
The authorsuof the present series dismiss completely
e P duct exploration
.
trans-cystic
and indicate that direct
e
)
r supraduodenal
f
CBD exploration is preferred in their
w
m
r
o
o
as it is more reliable. On the basis of my
fo institution
n
c and published evidence. I would
.
k
own
experience
e
l edhave otowdisagree with this. In the first instance,
b
n trans-cystic ductal clearance is infinitely
la M laparoscopic
i
k
a
d traumatic than supraduodenal choledochotomy,
by eless
There is good evidence from one large
i.e., it leaves the entire extrahepatic biliary tract in its
av multi-centre
d with.m pristine state and for this reason, recovery from this
RCT and a smaller single-centreisRCT together
e
t
w procedure is almost identical to that of LC alone. It is
that
single stage
many large non-randomized series
s
F
w
o symptomatic
laparoscopic treatment forD
patients with
to about 60% of cases. The size of stone(s)
h
P is asesafe and as(weffective applicable
gallstones and ductal calculi
which can be extracted through the cystic duct
t
s (endoscopic
i
i
as two-stage treatment
stone extraction
obviously depends on the size of the cystic duct;
s
h
followed by laparoscopic
cholecystectomy),
but
it
although some actually balloon dilate the duct, a
T a
reduces costs and is kinder to the patients.
practice, which I do not advocate as it may induce
[2]
[3]
[4-8]
[2]
Nonetheless, the two-stage treatment continues to be
the most frequent form of management worldwide.
The reasons for this anachronistic situation in this era
of evidence-based medicine are several: turf battle and
dominant hold by gastroenterologists, the hassle factor
prevalent amongst many surgeons (cannot be
bothered to take on the extra work and training
entailed) and several unresolved surgical issues
regarding the actual intra-operative management,
1
[6,8]
splitting of the duct. Obviously there are cases where
trans-cystic duct clearance is not applicable - large
stones (>8 mm), occluding stones, excessive stone
load in a grossly dilated common bile duct. But in all
other instances, the trans-cystic duct clearance (with
blind trawling or visually guided through a minicholedochoscope) should be tried first and direct
supraduodenal exploration kept in reserve in the event
of failure.
Journal of Minimal Access Surgery | January-March 2007 | Volume 3 | Issue 1
CMYK1
Cuschieri: Laparoscopic bile duct surger y
NEED FOR DRAINAGE OF THE CBD
INDICATIONS FOR BILIO-ENTERIC DRAINAGE
There is no need for drainage of the CBD after
successful trans-cystic ductal clearance as there is no
sutured choledochotomy to protect. Most would
drain the CBD after successful supraduodenal
choledochotomy to ensure decompression, which
reduces the risk of post-operative bile leakage.
However, not all agree with this and some close the
choledochotomy without drainage.[5] These are brave
surgeons as flow debimetry studies have shown that
there is indeed a temporary period (several days) of
impaired emptying through the choledochal sphincter
especially after instrumental manipulation inside the
CBD.[9] The question is how? It is my strong belief
that T-tube drainage should be dropped from surgical
laparoscopic bile duct surgical practice as it negates
all the advantages of the laparoscopic approach and
contributes substantially to the post-operative
morbidity.[2] In which case, the options available to
the laparoscopic surgeon who believes that
decompression is advisable are two: (i) insertion of
an endo-biliary stent as reported in this series and
used by many other surgeons or (ii) use of a cystic
duct drainage cannula (Fr 8) introduced and practised
by the author. [10,11] This cannula (Wilson Cook) is
inserted into the CBD through the cystic duct to which
it is doubly tied with absorbable material. The
choledochotomy is then sutured. The cystic duct
drainage cannula usually drains approximately
500 mL of bile in first 24 hours after which a postoperative cholangiogram is performed through the
cannula. If this is normal, the cannula is capped (Luerlock fitting cap) and then coiled and covered with an
occlusive bandage; the patient being discharged the
following day. The cannula is removed as an
outpatient 10 days later (longer in diabetics and the
elderly). The relative benefits between the two
options - temporary stenting versus cystic duct
drainage cannula have never been studied but
obviously the stent option incurs greater costs
because it necessitates a subsequent flexible
endoscopy. Other than reduced costs, the other
advantage of the cystic duct drainage cannula is that
it permits a postoperative contrast study confirming
that the ductal stone clearance has indeed been
complete.
This was considered necessary in 59 patients in the
present series (33%). This is higher than expected from
reported series in the West. It may of course indicate
more severe and advanced ductal stone disease in
India. Either way, it does raise the matter of
indications for this added procedure, which are not
discussed in the reported laparoscopic surgical
literature. In my own practice a bilio-enteric by-pass,
usually a transection choledochoduodenostomy, is
reserved for patients with ducts exceeding 20 mm
and a large stone load. Am I denying some patients the
possible benefit of bilio-enteric drainage or am I being
sensible and cautious?
m
o
fr
REFERENCES d
a ns
o
l tio
n
w lica
o
d ub
e
re w P ).
f
r o om
o
f kn .c
e
l ed ow
b
la M kn
i
a y ed
v
a db m
is te w.
F os w
D
P e h (w
is sit
h
T a
1.
Bandyopadhyay SK, Khanna S, Sen B, Tantia O. Antegrade common
bile duct (CBD) stenting after laparoscopic CBD exploration. J
Min Access Surg 2007;3:19-25.
2. Cuschieri A, Lezoche E, Morino M, Croce E, Lacy A, Toouli J, et al.
E.A.E.S. multicenter prospective randomized trial comparing
twostage vs single-stage management of patients with gallstone
disease and ductal calculi. Surg Endosc 1999;13:952-7.
3. Rhodes M, Sussman L, Cohen L, Lewis MP. Randomise trial of
laparoscopic exploration of the common bile duct versus
postoperative endoscopic retrograde cholangiography for
common bile duct stones. Lancet 1998;351:159-61.
4. Tranter SE, Thompson MH. Comparison of endoscopic
sphincterotomy and laparoscopic exploration of the common
bile duct. Br J Surg 2002;89:1495-504.
5. Decker G, Borie F, Millat B, Berthou JC, Deleuze A, Drouard F, et al.
One hundred laparoscopic cholecystectomies with primary
closure of the common bile duct. Surg Endosc 2003;17:12-8.
6. Petelin JB. Laparoscopic common bile duct exploration. Surg
Endosc 2003;17:705-9.
7. Waage A, Stromberg G, Leijonmarck CE, Arvidssson D. Long-term
results from laparoscopic common bile duct exploration. Surg
Endosc 2003;17:1181-5.
8. Paganini AM, Guerrieri M, Sarnari J, De Sanctis A, D’Ambrosio G,
Lezoche G, et al. Thirteen years’ experience with laparoscopic
transcystic common bile duct exploration for stones. Surg Endosc
2007;21:34-40.
9. Holdsworth RJ, Sadek SA, Ambikar S, Baker PR, Cuschieri A.
Dynamics of bile flow through the human choledochal sphincter
following exploration of the common bile duct. World J Surg
1989;13:300-6.
10. Shimi S, Banting S, Cuschieri A. Transcystic duct drainage after
laparoscopic drainage of the common bile duct. Min Invas Ther
1992;1:273-6.
11. Hensman C, Crosthwaite G, Cuschieri A. Transcystic biliary drainage
after direct laparoscopic exploration of the common bile duct.
Surg Endosc 1997;11:1106-10.
Cite this article as: Cuschieri A. Laparoscopic bile duct surgery: Home
truths. J Min Access Surg 2007;3:1-2.
Journal of Minimal Access Surgery | January-March 2007 | Volume 3 | Issue 1
2 CMYK
2
Related papers
Contingent Contradictions and the (Il)Logics of Adolescence: Examining How Undergraduates in an LGBTQ+ Young Adult Literature Course Read Queer Youth
Reading Research Quarterly, 2024
Zablotsky & Thompson, Decolonize the City, Nationalism and Difference (in German)
Decolonize the City! Zur Kolonialität der Stadt – Gespräche | Aushandlungen | Perspektiven, 2017
Effets de la dette publique sur les investissement dans l'UEMOA
The Economics & Management Reviews, 2024
«La casa y capilla de Santa Lucía de Segorbe. Un lugar de breve descanso espiritual para el viajero en la ruta del Camino Real»
Boletín Oficial Diócesis de Segorbe-Castellón, 2023
Categorizing concept predications and participations in Platonic dialogues: An exhaustive analysis of the various types of participation of things and ideas in ideas throughout the Platonic work
Plato Journal, Issue 25, pp. 25-43, 2024, available at: https://impactum-journals.uc.pt/platojournal/article/view/9805/9954, 2024
ÇOCUK EDEB‹YATI PANEL‹ Çocu¤u Anlayan Edebiyat
Çocuğu Anlayan Edebiyat Paneli, 2007
Preparation and properties of active dansyl-α- and -γ-thrombins
Archives of Biochemistry and Biophysics, 1981
A Multicenter Study to Validate Magnetic Resonance Enterography Against Histological Assessments of Stenotic Disease in Patients with Crohn's Disease
Gastroenterology, 2017
Myelomatous Pleural Effusion: A Rare Involvement in Myeloma
Journal of Medical Cases, 2020
Norovirus Monitoring in Bivalve Molluscs Harvested and Commercialized in Southern Italy
Journal of Food Protection, 2012
Study of Mechanical Properties of Wood Dust Reinforced Epoxy Composite
Procedia Materials Science, 2014
The Effects of Impaired Arm Function on Quality of Life in Breast Cancer Survivors
Medicine & Science in Sports & Exercise, 2017
Physical Properties of Spray-dried Pink Guava (Psidium Guajava) Powder
Agriculture and Agricultural Science Procedia, 2014
Nutritional and sensory quality of wheat bread supplemented with stabilized rice bran
FOOD SCIENCE RESEARCH JOURNAL, 2017