Common Bile Duct Stone Management: What Have we Learned?
Condition: Common Bile Duct Stones
Study type: Observational

Summary: 
      In unfit elderly people with comorbid disease leaving the gallbladder in situ is justified
      after ERCP treatment. Cholangitis is more present in elderly people. The purpose of this
      study is to determine leaving the gallbladder in situ does not reduce the morbidity rate
      after ERCP for common bile duct stones(CBDS), especially in patients with cholangitis.
    

Detailed description: 
      The prevalence of gallstone disease increases with age, and as many as one third of women and
      one fifth of men over the age of 60 years have gallstones. The quoted prevalence of CBDS in
      patients with symptomatic gallstones varies, but probably lies between 10 and 20%. In Europe
      and Northern America 8 to 20% of cases of cholelithiasis is complicated by presence of common
      bile duct stones (CBDS) during cholecystectomy. When ductal stones do become symptomatic the
      consequences are often serious and can include pain, partial or complete biliary obstruction,
      cholangitis, hepatic abscesses or pancreatitis. Recent guidelines for the treatment of CBDS
      recommend that in patients with symptoms and clinical evaluation suggesting ductal stones as
      a cause, stones should be extracted if possible, except in selected patients that have
      contraindications (e.g high risks patients, refusal of endoscopic or operative treatment).

      Many different approaches are currently being used for the management of bile duct calculi.
      These strategies differ considerably in terms of technical complexity, sensitivity,
      specificity, effectiveness, and cost. Where initial assessment suggests a high probability of
      CBDS, then it is reasonable to proceed directly to ERCP if this is considered the treatment
      of choice. Intraoperative cholangiography with selective intraoperative or postoperative ERCP
      is a strategy than routine preoperative ERCP, unless the presence of common bile duct stones
      (CBD) is almost certain. Current data does not suggest clear superiority of any one approach
      with regard success, mortality, morbidity and cost-effectiveness. In unfit elderly people
      with comorbid disease leaving the gallbladder in situ is justified after ERCP treatment.
      Cholangitis is more present in elderly people. Leaving the gallbladder in situ does not
      reduce the morbidity rate after ERCP for CBDS, especially in patients with cholangitis

      All 101 patients with symptomatic and suspected CBD stones admitted to Surgical Department of
      "Ospedale Regionale di Mendrisio" from january 2006 to december 2013 were evaluated
      retrospectively for study eligibility. Patients were followed for the duration of hospital
      stay, the median hospital stay was 9 days.

      From our Hospital informatic system, information on age, sex, length of hospital stay, and
      procedures undertaken during hospital admissions for patients with biliary diagnoses were
      retrieved. Initial patient evaluations consisted of history and physical examinations and
      serum analyses for inflammatory parameters, bilirubin, alkaline phosphatase, transaminase,
      and amylase. Previous history of jaundice or acute pancreatitis was recorded. In addition,
      right upper quadrant abdominal sonograms and CT scan were obtained for the determination of
      cholelithiasis and CBD diameter. The diagnosis of cholangitis was based on presence of
      clinical evidence of infection in patients with biliary obstruction in the form of jaundice
      or hyperbilirubinemia.

      In our institution, patients with cholelithiasis, a CBD stones at US examination, and liver
      enzyme elevation, without clinical evidence of cholecystitis or biliary pancreatitis
      underwent ERCP, endoscopic sphincterotomy, and endoscopic clearance of CBD stones before
      laparoscopic cholecystectomy (LC). In patients with acute cholangitis, a dilated common bile
      duct on US, the first treatment was also ERCP. Patients with cholelithiasis, CBD and
      intrahepatic bile duct (IHBD) dilatation, and liver enzyme elevation, in the presence of
      cholecystitis, biliary pancreatitis, or apparent resolving symptomatic choledocholithiasis
      underwent further evaluation with magnetic resonance imaging(MR), and these patients
      underwent therapeutic ERCP when choledocholithiasis was demonstrated by MR, whereas patients
      whose MR did not detect choledocholithiasis underwent LC with intraoperative cholangiography
      (IOC). When we found CBD during LC, an ERCP was performed in the same operating time
      ("rendez-vous") or post operatively.

      Endoscopic retrograde cholangiopancreatography(ERCP) with papillotomy was performed in
      patients with confirmed common bile duct stones(CBDS) by a single gastroenterologist.

      In our Hospital, the procedure is performed in radiological room that contains x-ray
      equipment. We use a Olympus® duodenalendoscope TJF-145 for ERCP, Erbe® system for papillotomy
      diathermy, and Lithotriptor® if stone crushing is necessary. The patient is in prone position
      under general anesthesia. When performing endoscopic stone extraction the endoscopist has the
      support of a technician or radiologist who can assist in fluoroscopic screening and an
      additional endoscopy assistant/nurse to manage guide wires.

      The relationship between ERCP and surgery was assessed by dividing the patients into 2
      groups: patients who had ERCP without cholecystectomy (Group 1), patients who had ERCP +
      cholecystectomy (Group 2). Endpoint was to detect difference in age, indication (cholangitis
      and lithiasis), morbidity, effectiveness and success of CBD clearance in different groups.
    

Observational model: Cohort
Time perspective: Retrospective
Sampling method: Non-Probability Sample
Study population: 
        Primary care clinic
      
Keywords: CBDS; ERCP; Dindo-Clavien classification