Management of cbd stones a study

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Proper Timing of Elective LaparoscopicCholecystectomy After Endoscopic

Retrograde Cholangiopancreatography With Sphincterotomy: A Prospective

Observational Study

Proper Timing of Elective LaparoscopicCholecystectomy After Endoscopic

Retrograde Cholangiopancreatography With Sphincterotomy: A Prospective

Observational Study

ByTamer Rushdy Hosseini

Assistant Lecturer of General SurgeryAssistant Lecturer of General SurgeryFaculty of Medicine - Zagazig UniversityFaculty of Medicine - Zagazig University

ByTamer Rushdy Hosseini

Assistant Lecturer of General SurgeryAssistant Lecturer of General SurgeryFaculty of Medicine - Zagazig UniversityFaculty of Medicine - Zagazig University

First of all, my thankful to First of all, my thankful to ALLAH, ALLAH, who who gave me the strength to finish this workgave me the strength to finish this work..

My greatest sincere gratitude and deep appreciation to Hemeida Elsayed Mohammed, Professor of General Surgery, Faculty of Medicine, Zagazig University, for being highly caring, helpful and supportive for me. His paternal advices were kindly given to me that helped to bring this work into light.

Words fail to express my sincere gratitude to Abdel-Rahman Hassan Sadek, Professor and Head of General Surgery Department, Faculty of Medicine, Zagazig University, who scarified a great deal of his valuable time and experience to guide me throughout the whole work.

Last but not least, I wish to express my sincere appreciation to Prof. Dr Samir Ibrahim Mohammed, Professor of General Surgery, Faculty of Medicine, Zagazig university, for his continuous effort and energetic help without which this work would have never been completed.

Common bile duct stones Common bile duct stones occurs in 10-15% of patients with occurs in 10-15% of patients with symptomatic gallstone disease. symptomatic gallstone disease. In general, common bile duct In general, common bile duct stones should be removed stones should be removed because they may be associated because they may be associated with complications such as with complications such as gallstone pancreatitis and gallstone pancreatitis and cholangitischolangitis

Common bile duct stones Common bile duct stones occurs in 10-15% of patients with occurs in 10-15% of patients with symptomatic gallstone disease. symptomatic gallstone disease. In general, common bile duct In general, common bile duct stones should be removed stones should be removed because they may be associated because they may be associated with complications such as with complications such as gallstone pancreatitis and gallstone pancreatitis and cholangitischolangitis

There is at present no consensus on the ideal management of common bile duct stones

ERCP then laparoscopic cholecystectomy versus single-stage laparoscopy,

postoperative endoscopic retrograde cholangio-pancreatography versus laparoscopic choledochotomy,

preoperative versus postoperative endoscopic retrograde cholangio-pancreatography .

There is at present no consensus on the ideal management of common bile duct stones

ERCP then laparoscopic cholecystectomy versus single-stage laparoscopy,

postoperative endoscopic retrograde cholangio-pancreatography versus laparoscopic choledochotomy,

preoperative versus postoperative endoscopic retrograde cholangio-pancreatography .

An accepted treatment strategy for cholelithiasis with secondary choledocholithiasis is the laparoscopic cholecystectomy following endoscopic retrograde cholangiopancreatography. Although early cholecystectomy is advised, there is no consensus about the time interval between laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography

An accepted treatment strategy for cholelithiasis with secondary choledocholithiasis is the laparoscopic cholecystectomy following endoscopic retrograde cholangiopancreatography. Although early cholecystectomy is advised, there is no consensus about the time interval between laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography

We do not know enough about the effects of:

the time elapsed between ERCP and laparoscopic cholecystectomy on operation and operation outcomes .

Intraoperative and postoperative complications and conversion to open surgery have been reported to be more frequent in patients who undergo ERCP prior to laparoscopic cholecystectomy. However, the mechanisms underlying this pattern have not been identified

Intraoperative and postoperative complications and conversion to open surgery have been reported to be more frequent in patients who undergo ERCP prior to laparoscopic cholecystectomy. However, the mechanisms underlying this pattern have not been identified

The aim of this work was to establish the feasibility, complications and outcome of different time intervals between endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy in management of common bile duct stones.

The aim of this work was to establish the feasibility, complications and outcome of different time intervals between endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy in management of common bile duct stones.

This study was carried out on 60 patients who were randomized by systematic randomization into three equal groups according to the interval between endoscopic retrograde cholangiopancreato-graphy and laparoscopic chole-cystectomy defined as short (3days or less), medium (4–60days) or long (60 days or more)

This study was carried out on 60 patients who were randomized by systematic randomization into three equal groups according to the interval between endoscopic retrograde cholangiopancreato-graphy and laparoscopic chole-cystectomy defined as short (3days or less), medium (4–60days) or long (60 days or more)

All patients have undergone endoscopic retrograde cholangio-pancreatography with sphincterotomy followed by elective laparoscopic cholecystectomy

All patients have undergone endoscopic retrograde cholangio-pancreatography with sphincterotomy followed by elective laparoscopic cholecystectomy

Inclusion criteria: Inclusion criteria:

Patients who had been admitted to our department for cholelithiasis were evaluated for the risk of CBDS. The indications for ERCP were one or more of the following: elevated serum bilirubin level ,elevated alkaline phosphatase,GGT,dilated common bile duct (≥8 mm) and/or stones in common bile duct at ultrasonographic (US) examination

Patients who had been admitted to our department for cholelithiasis were evaluated for the risk of CBDS. The indications for ERCP were one or more of the following: elevated serum bilirubin level ,elevated alkaline phosphatase,GGT,dilated common bile duct (≥8 mm) and/or stones in common bile duct at ultrasonographic (US) examination

Exclusion criteria: Exclusion criteria:

The patients who has complications related to endoscopic retrograde cholangiopancreatography was excluded from our study

The patients who has complications related to endoscopic retrograde cholangiopancreatography was excluded from our study

Patients with findings of acute cholecystitis, pancreatitis, cholangitis and patients with contrast agent allergies or known inflammatory disease was excluded from the study, as inflammation can interfere with the study.

Patients with findings of acute cholecystitis, pancreatitis, cholangitis and patients with contrast agent allergies or known inflammatory disease was excluded from the study, as inflammation can interfere with the study.

Patients with previous upper abdominal operation, history of peritonitis or history of endoscopic retrograde cholangiopancreatography will be excluded from the study because of intraabdominal adhesions risk .

Patients with previous upper abdominal operation, history of peritonitis or history of endoscopic retrograde cholangiopancreatography will be excluded from the study because of intraabdominal adhesions risk .

Investigations:Investigations:

1- Laboratory:- A- Routine laboratory investigations:-- 1.Urine analysis 2. Complete blood count. 3. Fasting blood sugar. 4. Urea and creatinine in serum.5. Liver function tests (total bilirubin, direct bilirubin, total protein, AST, ALT, ALP, GGT and prothrombin time).B- Specific laboratory investigations: - e.g. Lipase, amylase.

1- Laboratory:- A- Routine laboratory investigations:-- 1.Urine analysis 2. Complete blood count. 3. Fasting blood sugar. 4. Urea and creatinine in serum.5. Liver function tests (total bilirubin, direct bilirubin, total protein, AST, ALT, ALP, GGT and prothrombin time).B- Specific laboratory investigations: - e.g. Lipase, amylase.

2- Imaging studies:-A- Transabdominal ultrasonogrphy:- It was done for all patients using .We looked at, gall bladder stones, signs of acute or chronic cholecystitis, (CBD) dilatation or stones. Also, we looked at the liver for diseases as cirrhosis, fibrosis, dilated intrahepatic radicals.

2- Imaging studies:-A- Transabdominal ultrasonogrphy:- It was done for all patients using .We looked at, gall bladder stones, signs of acute or chronic cholecystitis, (CBD) dilatation or stones. Also, we looked at the liver for diseases as cirrhosis, fibrosis, dilated intrahepatic radicals.

B- Magnetic resonance cholangiopancreatico raphv (MRCP) :

It was used in patients with positive history suggestive of biliary stone disease and ultrasonography did not reveal stones in a dilated CBD.

B- Magnetic resonance cholangiopancreatico raphv (MRCP) :

It was used in patients with positive history suggestive of biliary stone disease and ultrasonography did not reveal stones in a dilated CBD.

The operative interventions : The operative interventions :

All patients were managed by endoscopic retrograde cholangio-pancreatography with sphincterotomy followed by elective laparoscopic cholecystectomy

All patients were managed by endoscopic retrograde cholangio-pancreatography with sphincterotomy followed by elective laparoscopic cholecystectomy

All patients were informed in detail about the risk and the benefits of each protocol, and a written informed consent was obtained from all of them

All patients were informed in detail about the risk and the benefits of each protocol, and a written informed consent was obtained from all of them

Demographic data of included patients. Demographic data of included patients.

N = 60

Age / years

X SD 38.5 11.8

Range 20-65

Number Percent (%)

Gender

Male 22 36.7

Female 38 63.3

The distribution of patients according to gender The distribution of patients according to gender

3822

Female

Male

Relation between Demographic data ,clinical history and different study groups Relation between Demographic data ,clinical history and different study groups

I (n = 20) II (n = 20) III (n = 20) F P

Age / years

X SD 38.5 11.8 39.1 12.9 38.4 11.4

Range 21- 60 20 - 65 23.65

0.03 0.96

No. (%) No. (%) No. (%) X2 P

Gender

Male 5 25 9 45 8 40

Female 15 75 11 55 12 60

1.87 0.39

History of acute cholecystitis 18 40 2 10 7 35 5.09 0.07

History of Jaundice 16 80 14 70 12 60 1.9 0.38

History of Pancreatitis 1 5 0 0 1 5 1.03 0.6

Intraoperative findings and complications among studied group

Intraoperative findings and complications among studied group

I (n = 20) II (n = 20) III (n = 20) X2 P

1- Adhesions

Type 1 11(55.0) 5(25.0) 3(15.0)

Type 2 8(40.0) 6(30.0) 7(35.0)

Type 3 1(5.0) 8(40.0) 9(45.0) 15.52 0.04*

Type 4 0(0.00) 1(5.0) 1(5.0)

Viceral injury 0(0.0) 0(0.0) 0(0.0) 0 1

Intraoperative bleeding 1(5) 3(15) 1(5) 1.75 0.4

Gall bladder rupture 1(5) 2(10) 1(5) 0.54 0.76

Intraoperative CBD injury 0(0) 0(0) 1(5) 2.03 0.36

Conversion 0(0) 2(10) 1(5) 2.11 0.34

Operative time X SD

39.515.5 54.7 23 57.3 19.1 4.7 0.012*

Percentage of Intraoperative adhesions among studied group Percentage of Intraoperative adhesions among studied group

Group 1

055540

Type 1 type 2 Type 3 Type 4

Group II

5

40

25

30

Type 1 type 2 Type 3 Type 4

Group III

5

35

1545

Type 1 type 2 Type 3 Type 4

Mean operative time in the studied groups Mean operative time in the studied groups

57.354.7

39.5

0

10

20

30

40

50

60

70

Group I Group II Group III

Mea

n o

per

ativ

e ti

me

(min

.)Group I Group II Group III

Mean hospital stay in the studied groups Mean hospital stay in the studied groups

2.75

2

1.5

0

0.5

1

1.5

2

2.5

3

Group I Group II Group III

Mea

n ho

spita

l sta

y (d

ay)

Group I Group II Group III

Postoperative findings among studied groups Postoperative findings among studied groups

I (n = 20) II (n = 20) III (n = 20) X2 P

No % No % No % No %

Postoperative CBD injury 0 0 0 0 0 0 0 1

Postoperative collection 0 0 1 5 0 0 2.03 0.36

Postoperative wound infection

1 5 4 20 2 10 2.26 0.3

Postoperative pain

Type 1 12 60 5 25 10 50

Type 2 7 35 10 50 8 40 6.7 0.1

Type 3 1 5 5 25 2 10

Hospital stay X SD

1.5 0.6

2 0.8

2.75 2.3

3.61

0.03*

Range 1-3 1 – 4 1-10

Mortality 0 0 0 0 1

Among patients who undergo LC, preoperative ERCP has been associated with more frequent intraoperative and postoperative complications and conversion to open surgery .

Among patients who undergo LC, preoperative ERCP has been associated with more frequent intraoperative and postoperative complications and conversion to open surgery .

Conversion to open surgery and serious intra and post operative complications did not show to be affected by the time interval between ERCP and Laparoscopic cholecystectomy

Conversion to open surgery and serious intra and post operative complications did not show to be affected by the time interval between ERCP and Laparoscopic cholecystectomy

The main difference between the groups showed to be in the score of encountered intraoperative adhesions in favor of the short interval group .

The main difference between the groups showed to be in the score of encountered intraoperative adhesions in favor of the short interval group .

Shorter operative time and hospital stay remarked in the early group with less cost and earlier return to work

Shorter operative time and hospital stay remarked in the early group with less cost and earlier return to work

Translation of the research to practice is the final aim of any research.

Translation of the research to practice is the final aim of any research.

Our recommendation that early LC(within 72 hours of ERCP) should be the adopted policy because of less adhesions, shorter operative time, hospital stay

Our recommendation that early LC(within 72 hours of ERCP) should be the adopted policy because of less adhesions, shorter operative time, hospital stay

Further study is needed to evaluate Further study is needed to evaluate recurrent biliary symptomps during the recurrent biliary symptomps during the waiting period and the conversion rate and waiting period and the conversion rate and complications in larger studiescomplications in larger studies

Further study is needed to evaluate Further study is needed to evaluate recurrent biliary symptomps during the recurrent biliary symptomps during the waiting period and the conversion rate and waiting period and the conversion rate and complications in larger studiescomplications in larger studies

THANKTHANK

YOUYOU

THANKTHANK

YOUYOU