Predicting common bile duct lithiasis: Determination and prospective validation of a model predicting low risk

doi:10.1016/S0002-9610(99)80249-9

The American Journal of Surgery

Volume 170, Issue 1, July 1995, Pages 38-43

https://doi.org/10.1016/S0002-9610(99)80249-9 Get rights and content

Abstract

Background: The aim of this two-part prospective study was: (1) to identify simple, noninvasive, preoperative factors associated with low or very low risk of common bile duct lithiasis (CBDL); and (2) to test the validity of the statistical model obtained during Part One by the postcholecystectomy follow-up of patients classified into a low-risk group.

Patients and methods: In Part One of the study, preoperative clinical, biologic, and ultrasonographic data, and intraoperative cholangiographic findings were collected from 503 consecutive patients undergoing cholecystectomy for symptomatic lithiasis from 1985 to 1989. Using the data obtained in Part One, a linear logistic model was used prospectively in Part Two to determine the prediction of absence of CBDL in 279 consecutive patients. No jaundice, normal transaminase levels, common bile duct (CBD) diameter <8 mm, and no intrahepatic duct enlargement defined the low-risk group of CBDL.

Results: In Part One, CBDL was present in 84 (17%) of all patients. Five parameters were used to classify 73% of all patients as low risk of CBDL and 27% as high risk. In the low-risk groups, CBDL was present in 1% of 116 cases with acute gallbladder complications, and 5% of 250 cases with no acute gallbladder complications.

In Part Two, 171 (61%) patients were classified in the low-risk group (Group 1), and CBD stones were not sought by any additional preoperative investigations or intraoperative cholangiography (IOC). One hundred eight patients (39%) were considered at risk of CBDL (Group 2). Mean follow-up was 20.6 months (median 19); 2 patients (1%) in the low-risk group presented a symptomatic retained stone.

Conclusions: This study validated this simple model for predicting risk of CBDL and avoiding invasive preoperative investigations—as well as IOC—in more than 60% of symptomatic cholelithiases. In addition, this model seemed useful for defining patients in whom further exploration for CBDL was justified, since 42 (39%) of the 108 Group 2 patients were proved to have CBDL.

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Success of intraoperative imaging and management of suspected choledocholithiasis without pre-operative bile duct imaging – A case series
2018, Annals of Medicine and Surgery
Laparoscopic common bile duct exploration (LCBDE) is gaining popularity over endoscopic retrograde cholangiopancreatography (ERCP) for the management of common bile duct stones. However, its application has been almost exclusively following preoperative stone confirmation via magnetic retrograde cholangiopancreatography (MRCP), endoscopic ultrasound (EUS) or ERCP. We present our series of LCBDE following detection of common bile duct stones with intraoperative imaging (IOI) alone, in consecutive elective and emergency patients with suspected choledocholithiasis.
All patients with suspected but unconfirmed choledocholithiasis undergoing LC with intention to proceed to LCBDE between January 2015 and June 2017 were included. LCBDE was performed following the discovery of choledocholithiasis on IOI.
371 patients with suspected choledocholithiasis underwent LC with IOI. CBD stones or obstructing sludge was identified in 107 patients (29%), with sensitivity of 96.2% and specificity of 98.5%. 100 patients, median age 59, went on to have LCBDE as indicated by intraoperative imaging. 76% were performed as emergency cases and conversion to open rate was 2%. There were no mortalities. Bile leak and retained stones occurred in 4% and 3% respectively. 7/100 patients required re-intervention, with re-look laparoscopy (n = 4) and ERCP (n = 3). Median length of stay was 1.5 and 3 days for elective and emergency cases respectively, and 30 readmission rate was 8%.
Traditionally patients presenting with suspicion of choledocholithiasis undergo preoperative MRCP/EUS and/or ERCP prior to eventual LC. We propose an alternative, more streamlined, pathway of treatment without requiring preoperative cholangiography, applicable to both elective and emergency patients.
Association Between Juxtapapillary Duodenal Diverticula and Risk of Choledocholithiasis: a Systematic Review and Meta-analysis
2018, Journal of Gastrointestinal Surgery
Studies have suggested that the presence of juxtapapillary duodenal diverticula (JDD) could be a predisposing factor for choledocholithiasis. This systematic review and meta-analysis was conducted with the aims to summarize all available evidence to better characterize the risk.
A literature search was performed using MEDLINE and EMBASE database from inception to January 2018. Cross-sectional studies that reported odd ratios (OR) comparing the risk of choledocholithiasis among individuals with JDD versus individuals without JDD were included. Pooled OR and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method.
Of 527 retrieved articles, 11 studies met our eligibility criteria and were included in analysis. We found a significant association between the presence of JDD and choledocholithiasis with the pooled OR of 2.30 (95% CI, 1.84–2.86). The statistical heterogeneity was moderate with an I² of 60%.
A significantly increased risk of choledocholithiasis among individuals with JDD was observed in this study.
Laparoscopic common bile duct exploration; a preferential pathway for elderly patients
2018, Annals of Medicine and Surgery
Citation Excerpt :
10-15% of patients presenting with gallstone disease have synchronous common bile duct (CBD) stones [1–3].
Laparoscopic common bile duct exploration (LCBDE) has emerged as a recommended alternative to endoscopic retrograde cholangiopancreatography (ERCP) for the management of choledocholithiasis. However, its use in the elderly has been limited, and evidence of its safety and efficacy in these patients is yet to be established. This study describes our experience of LCBDE in elderly patients, analysing the safety and efficacy of this technique in comparison to younger patients.
All patients undergoing laparoscopic cholecystectomy (LC) with LCBDE for choledocholithiasis in our unit between January 2015 and January 2017 were included. Data pertaining to patient demographics, comorbidities, investigations, operative technique and outcomes were analysed. Patients were divided into 2 groups based on age (Group A:<65 years vs Group B: >/ = 65 years) for comparative analysis.
124 patients (Group A: 65, Group B: 59) were included. Group B were more co-morbid and had a higher ASA grade than Group A. However, there was no significant difference between groups in rates of conversion to open or complications, including bile leak (3.1% vs 5.1%, p = 0.67), retained stone (4.6% vs 1.7%, p = 0.62), or complications according to Clavien-Dindo classification (p = 0.78). Re-intervention rates were also similar between groups (7.7% vs 3.4%, p = 0.44 and 3.1% vs 3.4%, p = 1.0 respectively), as was length of stay.
Despite higher frequency of comorbidities and ASA grade, LCBDE in elderly patients is safe and effective, and has similar outcomes to younger patients. Therefore elderly patients with choledocholithiasis should be offered LCBDE as an alternative to ERCP.
Early analysis of laparoscopic common bile duct exploration simulation
2017, American Journal of Surgery
Citation Excerpt :
Approximately 3–17% of patients with acute cholecystitis have concomitant choledocholithiasis.1–3
We developed a laparoscopic common bile duct exploration (LCBDE) simulation course for resident surgeons (RS) and practicing surgeons (PS). We hypothesized that course completion would provide LCBDE procedural skills and increase procedure utilization.
RS and PS were prospectively enrolled. Pre- and post-course ability were assessed with written examinations and LCBDE simulations. PS completed pre-course, post-course, and 1-year follow-up surveys (5-point Likert-type scale).
17 RS and 8 PS were enrolled. Median written test scores improved (70.0%–80.0%, p < 0.001) and median LCBDE simulation times (seconds) improved (585–314, p = 0.001) among all participants. Comparing RS and PS, median written assessment scores pre-course (70% vs 72.5%, p = 0.953) and post-course (77.5% vs 80.0%, p = 0.198) were not significantly different. Simulation completion times (seconds) improved similarly from pre-course (608.0 vs 521.5, p = 0.885) to post-course (314.0 vs 373.0, p = 0.287) between groups. PS comfort with LCBDE improved (2–4, p = 0.03). All PS reported LCBDE utilization 1 year post-course.
The LCBDE course is appropriate for RS and PS. PS also reported increased comfort with LCBDE and procedure utilization.
Protocol-Driven Management of Suspected Common Duct Stones
2017, Journal of the American College of Surgeons
Citation Excerpt :
An estimated 700,000 cholecystectomies occur annually in the US.6 The presence of common duct stones ranges between 10% and 20% of patients with symptomatic gallstones.7-10 Scoring systems, using traditional preoperative risk factors, have been developed to stratify the presence of common duct stones.
Common duct stones can be diagnosed by magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound (EUS)/ERCP, and intraoperative cholangiogram (IOC). In 2015, our group adopted a standard approach of preoperative EUS/ERCP followed by laparoscopic cholecystectomy for patients with an admission bilirubin >4.0 mg/dL. For bilirubin <4.0 mg/dL, laparoscopic cholecystectomy with IOC was the initial procedure. Postoperative EUS/ERCP with endoscopic sphincterotomy was pursued for positive IOC. Exclusions included clinical suspicion of malignancy and surgically altered anatomy making endoscopic management impractical.
A retrospective comparison of protocol and pre-protocol (baseline) patients was performed, looking at patient demographics, presence of pancreatitis, common duct stone risk factors, comorbidities, length of hospitalization, and postoperative morbidity. Statistical analysis was performed with t-test, chi-square, and Wilcoxon rank-sum test with significance at p < 0.05.
There were 56 patients in each group, with a mean ± SD age of 50.5 ± 20.88 years and 49.3 ± 20.92 years, respectively (p = NS). There were no significant differences between baseline and protocol patients with respect to individual and cumulative preoperative comorbidities, pancreatitis, elevation of liver function tests, bilirubin, common duct size, and postoperative morbidity. There were fewer endoscopies (22 vs 35; p = 0.014), and shorter length of stay in protocol patients (2.8 days vs 3.8 days; p = 0.025).
Protocol-driven management of patients with suspected common duct stones reduced the number of endoscopies and length of hospitalization, with no change in postoperative morbidity. This approach has the potential to decrease endoscopy-related morbidity and overall cost without affecting quality of care.
A simulator-based resident curriculum for laparoscopic common bile duct exploration
2014, Surgery (United States)
Laparoscopic common bile duct exploration (LCBDE) remains an underused treatment for choledocholithiasis, likely in part because of a lack of exposure to the procedure during surgery residency. In this study, we implemented a resident LCBDE curriculum using a previously validated procedural simulator.
Senior surgery residents underwent a curriculum consisting of deliberate practice using the LCBDE simulator. Residents performed a simulated transcystic and transcholedochal LCBDE before and after completing the curriculum, which were rated by three faculty. Passing scores were determined using an Angoff method.
Ten residents participated. For transcystic LCBDE, all 10 residents failed the pretest. Assessment scores improved after the curriculum (20 ± 4 vs 41 ± 2; scale 0−45, P < .01), and all 10 residents passed the posttest. For transcholedochal LCBDE, all 10 residents failed the pretest. Transcholedochal scores improved after the curriculum (27 ± 6 vs 46 ± 4; scale 0−53, P < .01). Eight residents passed the initial posttest and two failed because they sutured the t-tube into the choledochotomy closure. Both underwent remedial training and passed a retest. Resident confidence in performing LCBDE clinically improved for both transcystic and transcholedochal approaches.
This curriculum improved the ability of surgery residents to perform both transcystic and transcholedochal LCBDE on a procedural simulator.

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Scientific paperPredicting common bile duct lithiasis: Determination and prospective validation of a model predicting low risk

Abstract

Am J Surg

Am J Surg

Gastroenterology

Am J Surg

Am J Surg

A prospective analysis of 1,518 laparoscopic cholecystectomies

NEJM

A requiem for the routine operative cholangiogram

Surg Gynecol Obstet

Laparoscopic cholecystectomy and the common bile duct

Br J Surg

Applied Logistic Regression

Statistical value of various clinical parameters in predicting the presence of choledochal stones

Surg Gynecol Obstet

Predictive ability of choledocholithiasis indicators. A prospective evaluation

Ann Surg

Preoperative evaluation of the risk of common bile duct stones

Arch Surg

Prospective study of clinical and biochemical features of symptomatic choledocholithiasis

Dig Dis Sci

Operative cholangiography in elective cholecystectomy

Br J Surg

Selective or routine intraoperative cholangiography: a cost-effectiveness analysis

World J Surg

Selective use of operative cholangiography

World J Surg

The case for selective cholangiography

Am J Surg

The case for selective instead of routine operative cholangiography

Am Surg

Scientific paper
Predicting common bile duct lithiasis: Determination and prospective validation of a model predicting low risk