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Single-stage laparoscopic management for concomitant
gallstones and common bile duct stones versus two stages using ERCP
procedures
By:
Mohamed Tag El-Din Mohamed
General surgery specialist
Qena general hospital
Protocol Submitted for partial fulfillment of Doctor Degree in General
surgery
Under supervision of
Prof. Dr. Alaa Ahmed Redwan Professor of GIT surgery and laparoendoscopy
Faculty of medicine, Sohag University
Dr. Magdy Khalil Abd El-Mageed
Assistant professor of general surgery
Faculty of medicine, Sohag University
Dr. Ahmed Abd El-Kahaar Aldardeer
Lecturer of general surgery
Faculty of medicine, Sohag University
2017
Introduction O Gallbladder stone is a common cause for
abdominal pain.
O Gallstones are rarely an indication for
surgery, but 10% of the adult population live
with them without any related complications.
O Furthermore, 30% of the population over 70
years of age will have gallstone.
(Kenny R et al, 2014)
O As many as 35% of patients with gallstones will
ultimately become symptomatic and require
cholecystectomy.
O Gallstones can sometimes migrate out of the
gallbladder and become trapped in common bile
duct .
(Dasari et al, 2013).
O CBD stones is concomitant with
gallstones in approximately 3%-10% of
the patients.
O Between 10% and 18% of people
undergoing cholecystectomy for
gallstones have common bile duct stones.
(Bansal et al, 2014).
Clinical presentation
O Stones within the bile duct are often
asymptomatic and may be found
incidentally, however, more frequently
they lead to symptomatic presentation
with:
oBiliary colic
oAscending cholangitis
oObstructive jaundice
oAcute pancreatitis(Bansal et al, 2014).
Radiographic features
1. Ultrasound
O Sensitivity has been variably reported
between 13-55% .
O Findings include:
O Visualization of stone
O Dilated bile duct
(Frank Gaillard et al,2016)
2. CT abdomen
O Sensitivity of 65-88%
O Findings include
o Target sign: central rounded density stone surrounding
lower attenuating bile or mucosa
o Rim sign: stone is outlined by thin shell of density
o Crescent sign: bile eccentrically outlines luminal stone,
creating a low attenuation crescent
o Calcification of the stone: unfortunately only 20% of
stones are of high density
(Frank Gaillard et al,2016)
3. MRCP
O Sensitivity (90-94%) and specificity (95-
99%)
O Findings include Filling defects are seen
within the biliary tree
(Frank Gaillard et al,2016)
Management
O In the pre-endoscopy and pre-laparoscope
era, the standard treatment for patients
suffering from gallstones accompanied with
common bile duct stones was open
cholecystectomy and common bile duct
exploration.
(Bansal et al, 2014).
Open exploration of CBDO Kocher incision
O Choledochotomy Incision
O Exploring the CBD
O Extraction of stones
O Cholecystectomy
O Insertion of the T-Tube
O Drainage and Closure
(Carol E. H et al, 2013)
ERCPO With all the breakthrough of endoscopic
retrograde cholangiopancreatography
(ERCP), endoscopic stone removal grew
to become the treating preference for
removal of CBD stones .
O Two-stage management using ERCP
accompanied by laparoscopic
cholecystectomy is a very common
technique for treatment of gall bladder
and CBD stones.
(Pankaj Prasson et al, 2016).
O ERCP is a procedure that enables to
examine the pancreatic and bile ducts.
O An endoscope about the thickness of
index finger is placed through mouth and
into stomach and first part of duodenum.
(Pankaj Prasson et al, 2016).
O In the duodenum a small opening is
identified (ampulla) and a small plastic
tube (cannula) is passed through the
endoscope and into this opening.
O Dye (contrast material) is injected and X-
rays are taken to study the ducts of the
pancreas and liver.
(Pankaj Prasson et al, 2016).
O Another open channel in the endoscope
also allows other instruments to be
passed through it in order to perform
biopsies, to insert plastic or metal stents
or tubing to relieve obstruction of the bile
ducts, and to perform incisions by using
electrocautery.
(Pankaj Prasson et al, 2016).
Laparoscopic exploration of CBD
O The laparoscopic common bile duct
exploration is a potential option for
managing stones within the biliary tree at
the same time as laparoscopic
cholecystectomy.
(Pankaj Prasson et al, 2016).
O The procedure is performed with the
patient in the supine position, with the
surgeon on the patient’s right and the
assistant on the left.
O the laparoscopic monitor are placed at the
patient’s head to the right.
(Bansal et al, 2014).
Port sites
The 5.5-mm rigid choledochoscope was inserted through the
epigastric port
The bile duct stone was extracted via basket at the direct view.
Use the laparoscopic interrupted sutures to close the
choledochotomy.
Aim of WorkO The aim of this study is to compare between
the outcome of management of concomitantgallstones and common bile duct by two stage(ERCP+LC) versus one stage(LECBD+LC) asregard:
Intraoperative complications
Conversion to other procedure
Total operative time
Postoperative complications
Postoperative mortality
Retained CBD stones
Length of hospital stay
Patient satisfaction
Patients and Methods
O This retrospective and prospective study
will include patients with concomitant
gallstones and common bile duct in
General surgery department in sohag
university hospital.
Criteria for inclusion
1. Age 16 to 70 years.
2. Patients with gallbladder stones and
concomitant stones in the CBD.
3. Patients with or without Jaundice.
Criteria for exclusion
1. Acute cholecystitis.
2. Acute pancreatitis.
3. Uncorrectable coagulopathy.
4. Liver cirrhosis, mass or abscess.
5. Recurrent choledocholithiasis.
6. Malignant pancreatic or biliary tumors.
Preoperative Preparation1. Routine investigations in form of: complete
blood picture, prothrombin time and
concentration, blood glucose, serum
creatinine , complete liver functions,
serology, blood typing.
2. Radiological investigations in form of
abdominal U/S and MRCP.
3. Written informed consent will be taken from
all patients.
Operative managementO Group I patients underwent single-stage
laparoscopic CBD exploration (LCBDE)
and laparoscopic cholecystectomy (LC).
O Group II patients underwent a two-stage
procedure; ERCP for endoscopic
extraction of CBD stones followed by LC
(ERCP + LC) within the same hospital
admission.
Postoperative management
O Postoperatively, the patients were
followed up at 1 week, 2 weeks, 3 weeks,
6 week, and up to 3months by:
O clinically: pain, fever, jaundice, wound
condition
O laboratory: liver function test
O investigatory: abdominal U/S
O At a 6-week follow-up evaluation, overall
satisfaction was assessed on a verbal
rating scale with scores of 0 (not
satisfied), 1 (partially satisfied), 2
(satisfied), or 3 (very satisfied).
Primary end point:
O Defined as removal of CBD stones and
gallbladder by the intended approach
Secondary end points
O Intraoperative complications: CBD injury
O Operative time in minutes
O Postoperative complications: bile leak, hemorrhage,
pancreatitis
O Pain score: The pain score was calculated on a
visual analog scale ranging from 1 to 10.
O Hospital stay: The hospital stay was calculated in
group I as the number of days in the hospital after
surgery until the patient was discharge and in
group II as the total duration of stay for ERCP and
cholecystectomy.
O Patient satisfaction score: Patient satisfaction was
scored on a verbal rating scale with scores of 0
(not satisfied), 1 (partially satisfied), 2 (satisfied),
and 3 (very satisfied)