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Surgical Endoscopy

Erschienen in:

01.01.2010

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)

verfasst von: Renato Costi, Antonio Mazzeo, Francesco Tartamella, Christine Manceau, Bernard Vacher, Alain Valverde

Erschienen in: Surgical Endoscopy | Ausgabe 1/2010

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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.

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.

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.

See footnote 1.

See footnote 2.

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.

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Titel: 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)
verfasst von: Renato Costi
Antonio Mazzeo
Francesco Tartamella
Christine Manceau
Bernard Vacher
Alain Valverde
Publikationsdatum: 01.01.2010
Verlag: Springer-Verlag
Erschienen in: Surgical Endoscopy / Ausgabe 1/2010
Print ISSN: 0930-2794
Elektronische ISSN: 1432-2218
DOI: https://doi.org/10.1007/s00464-009-0511-6

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Abstract

Background

Methods

Results

Conclusions

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