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Preoperative Decision-Making Algorithm

  • Arslan Pannu
  • Ahmad Mirza
Chapter

Abstract

The diagnosis and management of common bile duct stones requires a thorough approach, which can often be challenging. Pathways for the diagnosis and management of suspected common bile duct stone patients presenting with distinct syndromes are presented to facilitate safe clinical practice. All patients with acute uncomplicated gallstone pancreatitis should be offered operative intervention at the index admission. Patients with severe or complicated pancreatitis should be stabilized and undergo delayed interval cholecystectomy once they have recovered. Acute cholangitis can manifest as mild, moderate, or severe disease. Endoscopic biliary decompression should be performed in all patients who fail to improve or are acutely unwell. Laparoscopic cholecystectomy should be considered in all cases of gallstone-related acute cholangitis to reduce long-term morbidity and mortality. Management of choledocholithiasis in patients with altered anatomy is complex and requires an individualized plan, and consultation with or transfer to a specialist center may be helpful. All patients with jaundice should be thoroughly investigated to identify underlying pathology and to initiate appropriate treatment. A single-session laparoscopic approach, incorporating routine intraoperative imaging and expertise in laparoscopic common bile duct exploration where available, facilitates the management of choledocholithiasis.

Keywords

Choledocholithiasis Intraoperative cholangiogram Pancreatitis Jaundice Cholangitis Laparoscopic ultrasound Laparoscopic bile duct exploration Single-session management 

References

  1. 1.
    Collins C, Maguire D, Ireland A, Fitzgerald E, O’Sullivan GC. A prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of choledocholithiasis revisited. Ann Surg. 2004;239(1):28–33.CrossRefGoogle Scholar
  2. 2.
    Hunter JG. Laparoscopic transcystic common bile duct exploration. Am J Surg. 1992;163(1):53–6. discussion 57–58CrossRefGoogle Scholar
  3. 3.
    Petelin JB. Laparoscopic common bile duct exploration. Surg Endosc. 2003;17(11):1705–15.CrossRefGoogle Scholar
  4. 4.
    Shojaiefard A, Esmaeilzadeh M, Ghafouri A, Mehrabi A. Various techniques for the surgical treatment of common bile duct stones: a meta review. Gastroenterol Res Pract. 2009;2009:840208.CrossRefGoogle Scholar
  5. 5.
    Martin CJ, Cox MR, Vaccaro L. Laparoscopic transcystic bile duct stenting in the management of common bile duct stones. ANZ J Surg. 2002;72(4):258–64.CrossRefGoogle Scholar
  6. 6.
    Cuschieri A, Lezoche E, Morino M, Croce E, Lacy A, Toouli J, Faggioni A, , Ribeiro VM, Jakimowicz J, Visa J, Hanna GB.. E.A.E.S. multicenter prospective randomized trial comparing two-stage vs single-stage management of patients with gallstone disease and ductal calculi. Surg Endosc 1999;13(10):952-957.CrossRefGoogle Scholar
  7. 7.
    Bansal VK, Misra MC, Rajan K, Kilambi R, Kumar S, Krishna A, Kumar A, Pandav CS, Subramaniam R, Arora MK, Garg PK. Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with concomitant gallbladder stones and common bile duct stones: a randomized controlled trial. Surg Endosc. 2014;28(3):875–85.CrossRefGoogle Scholar
  8. 8.
    Rogers SJ, Cello JP, Horn JK, Siperstein AE, Schecter WP, Campbell AR, Mackersie RC, Rodas A, Kreuwel HT, Harris HW. Prospective randomized trial of LC + LCBDE vs ERCP/S+LC for common bile duct stone disease. Arch Surg. 2010;145:28–33.Google Scholar
  9. 9.
    Koc B, Karahan S, Adas G, Tutal F, Guven H, Ozsoy A. Comparison of laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for choledocholithiasis: a prospective randomized study. Am J Surg. 2013;206:457–63.CrossRefGoogle Scholar
  10. 10.
    Noble H, Tranter S, Chesworth T, Norton S, Thompson M. A randomized, clinical trial to compare endoscopic sphincterotomy and subsequent laparoscopic cholecystectomy with primary laparoscopic bile duct exploration during cholecystectomy in higher risk patients with choledocholithiasis. J Laparoendosc Adv Surg Tech A. 2009;19:713–20.CrossRefGoogle Scholar
  11. 11.
    Rhodes M, Sussman L, Cohen L, Lewis MP. Randomised trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde cholangiography for common bile duct stones. Lancet. 1998;351:159–61.CrossRefGoogle Scholar
  12. 12.
    Isla A, Griniatsos J, Rodway A. Single-stage definitive laparoscopic management in mild acute biliary pancreatitis. J Laparoendosc Adv Surg Tech A. 2003;13(2):77–81.CrossRefGoogle Scholar
  13. 13.
    Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62(1):102–11.CrossRefGoogle Scholar
  14. 14.
    Ito K, Ito H, Whang EE. Timing of cholecystectomy for biliary pancreatitis: do the data support current guidelines? J Gastrointest Surg. 2008;12(12):2164–70.CrossRefGoogle Scholar
  15. 15.
    Kharbutli B, Velanovich V. Management of preoperatively suspected choledocholithiasis: a decision analysis. J Gastrointest Surg. 2008;12(11):1973–80.CrossRefGoogle Scholar
  16. 16.
    Kimura Y, Arata S, Takada T, Hirata K, Yoshida M, Mayumi T, et al. Gallstone-induced acute pancreatitis. J Hepatobiliary Pancreat Sci. 2010;17(1):60–9.CrossRefGoogle Scholar
  17. 17.
    Iranmanesh P, Frossard JL, Mugnier-Konrad B, Morel P, Majno P, Nguyen-Tang T, et al. Initial cholecystectomy vs sequential common duct endoscopic assessment and subsequent cholecystectomy for suspected gallstone migration: a randomized clinical trial. JAMA. 2014;312(2):137–44.CrossRefGoogle Scholar
  18. 18.
    Altieri MS, Yang J, Obeid N, Zhu C, Talamini M, Pryor A. Increasing bile duct injury and decreasing utilization of intraoperative cholangiogram and common bile duct exploration over 14 years: an analysis of outcomes in New York State. Surg Endosc. 2017;32(2):667–74.  https://doi.org/10.1007/s00464-017-5719-2.CrossRefPubMedGoogle Scholar
  19. 19.
    Nassar AH, Mirza A, Qandeel H, Ahmed Z, Zino S. Fluorocholangiography: Reincarnation in the laparoscopic era-evaluation of intra-operative cholangiography in 3635 laparoscopic cholecystectomies. Surg Endosc. 2016;30(5):1804–11.CrossRefGoogle Scholar
  20. 20.
    Cameron DR, Goodman AJ. Delayed cholecystectomy for gallstone pancreatitis: re-admissions and outcomes. Ann R Coll Surg Engl. 2004;86(5):358–62.CrossRefGoogle Scholar
  21. 21.
    Sandzen B, Rosenmuller M, Haapamaki MM, Nilsson E, Stenlund HC, Oman M. First attack of acute pancreatitis in sweden 1988 - 2003: incidence, aetiological classification, procedures and mortality - a register study. BMC Gastroenterol. 2009;9:18.CrossRefGoogle Scholar
  22. 22.
    Moreau JA, Zinsmeister AR, Melton LJ 3rd, DiMagno EP. Gallstone pancreatitis and the effect of cholecystectomy: a population-based cohort study. Mayo Clin Proc. 1988;63(5):466–73.CrossRefGoogle Scholar
  23. 23.
    McAlister VC, Davenport E, Renouf E. Cholecystectomy deferral in patients with endoscopic sphincterotomy. Cochrane Database Syst Rev. 2007;4:CD006233.Google Scholar
  24. 24.
    Hernandez V, Pascual I, Almela P, Anon R, Herreros B, Sanchiz V, Minguez M, Benages A. Recurrence of acute gallstone pancreatitis and relationship with cholecystectomy or endoscopic sphincterotomy. Am J Gastroenterol. 2004;99(12):2417–23.CrossRefGoogle Scholar
  25. 25.
    da Costa DW, Bouwense SA, Schepers NJ, Besselink MG, van Santvoort HC, van Brunschot S, Dutch Pancreatitis Study Group, et al. Same-admission versus interval cholecystectomy for mild gallstone pancreatitis (PONCHO): a multicentre randomised controlled trial. Lancet. 2015;386(10000):1261–8.CrossRefGoogle Scholar
  26. 26.
    Targarona EM, Balague C, Espert JJ, Perez Ayuso RM, Ros E, Navarro S, et al. Laparoscopic treatment of acute biliary pancreatitis. Int Surg. 1995;80(4):365–8.PubMedGoogle Scholar
  27. 27.
    Stromberg C, Nilsson M. Nationwide study of the treatment of common bile duct stones in sweden between 1965 and 2009. Br J Surg. 2011;98(12):1766–74.CrossRefGoogle Scholar
  28. 28.
    Hwang SS, Li BH, Haigh PI. Gallstone pancreatitis without cholecystectomy. JAMA Surg. 2013;148(9):867–72.CrossRefGoogle Scholar
  29. 29.
    Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology. 2013;13(4 Suppl 2):e1–15.Google Scholar
  30. 30.
    Anonymous. UK guidelines for the management of acute pancreatitis. Gut. 2005;54(Suppl 3):iii1–9.Google Scholar
  31. 31.
    Forsmark CE, Baillie J. AGA Institute technical review on acute pancreatitis. Rev Gastroenterol Mex. 2007;72(3):257–85.PubMedGoogle Scholar
  32. 32.
    Uhl W, Warshaw A, Imrie C, Bassi C, McKay CJ, Lankisch PG, et al. IAP guidelines for the surgical management of acute pancreatitis. Pancreatology. 2002;2(6):565–73.CrossRefGoogle Scholar
  33. 33.
    Kimura Y, Takada T, Kawarada Y, Hirata K, Mayumi T, Yoshida M, et al. JPN guidelines for the management of acute pancreatitis: treatment of gallstone-induced acute pancreatitis. J Hepato-Biliary-Pancreat Surg. 2006;13(1):56–60.CrossRefGoogle Scholar
  34. 34.
    Trust MD, Sheffield KM, Boyd CA, Benarroch-Gampel J, Zhang D, Townsend CM Jr, Riall TS. Gallstone pancreatitis in older patients: are we operating enough? Surgery. 2011;150(3):515–25.CrossRefGoogle Scholar
  35. 35.
    Nealon WH, Bawduniak J, Walser EM. Appropriate timing of cholecystectomy in patients who present with moderate to severe gallstone-associated acute pancreatitis with peripancreatic fluid collections. Ann Surg. 2004;239(6):741–9. discussion 749–751CrossRefGoogle Scholar
  36. 36.
    Hanif F, Ahmed Z, Samie MA, Nassar AH. Laparoscopic transcystic bile duct exploration: The treatment of first choice for common bile duct stones. Surg Endosc. 2010;24(7):1552–6.CrossRefGoogle Scholar
  37. 37.
    Gough V, Stephens N, Ahmed Z, Nassar AH. Intrahepatic choledochoscopy during trans-cystic common bile duct exploration; technique, feasibility and value. Surg Endosc. 2012;26(11):3190–4.CrossRefGoogle Scholar
  38. 38.
    Darge K, Anupindi S. Pancreatitis and the role of US, MRCP and ERCP. Pediatr Radiol. 2009;39(Suppl 2):S153–7.CrossRefGoogle Scholar
  39. 39.
    Uhl W, Muller CA, Krahenbuhl L, Schmid SW, Scholzel S, Buchler MW. Acute gallstone pancreatitis: timing of laparoscopic cholecystectomy in mild and severe disease. Surg Endosc. 1999;13(11):1070–6.CrossRefGoogle Scholar
  40. 40.
    Folsch UR, Nitsche R, Ludtke R, Hilgers RA, Creutzfeldt W. Early ERCP and papillotomy compared with conservative treatment for acute biliary pancreatitis. The German Study Group on Acute Biliary Pancreatitis. N Engl J Med. 1997;336(4):237–42.CrossRefGoogle Scholar
  41. 41.
    van Santvoort HC, Besselink MG, de Vries AC, Boermeester MA, Fischer K, Bollen TL, et al. Early endoscopic retrograde cholangiopancreatography in predicted severe acute biliary pancreatitis: a prospective multicenter study. Ann Surg. 2009;250(1):68–75.CrossRefGoogle Scholar
  42. 42.
    Saik RP, Greenburg AG, Farris JM, Peskin GW. Spectrum of cholangitis. Am J Surg. 1975;130(2):143–50.CrossRefGoogle Scholar
  43. 43.
    Huibregtse K, Carr-Locke DL, Cremer M, Domschke W, Fockens P, Foerster E, et al. Biliary stent occlusion--a problem solved with self-expanding metal stents? European Wallstent Study Group. Endoscopy. 1992;24(5):391–4.CrossRefGoogle Scholar
  44. 44.
    Okamoto K, Takada T, Strasberg SM, Solomkin JS, Pitt HA, Garden OJ, et al. Tg13 management bundles for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2013;20(1):55–9.CrossRefGoogle Scholar
  45. 45.
    Takada T, Strasberg SM, Solomkin JS, Pitt HA, Gomi H, Yoshida M, et al. Tg13: updated tokyo guidelines for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2013;20(1):1–7.CrossRefGoogle Scholar
  46. 46.
    Boerma D, Rauws EA, Keulemans YC, Janssen IM, Bolwerk CJ, Timmer R, et al. Wait-and-see policy or laparoscopic cholecystectomy after endoscopic sphincterotomy for bile-duct stones: a randomised trial. Lancet. 2002;360(9335):761–5.CrossRefGoogle Scholar
  47. 47.
    Maple JT, Ikenberry SO, Anderson MA, Appalaneni V, Decker GA, Committee ASOP, et al. The role of endoscopy in the management of choledocholithiasis. Gastrointest Endosc. 2011;74(4):731–44.CrossRefGoogle Scholar
  48. 48.
    Bornman PC, van Beljon JI, Krige JE. Management of cholangitis. J Hepato-Biliary-Pancreat Surg. 2003;10(6):406–14.CrossRefGoogle Scholar
  49. 49.
    Boender J, Nix GA, de Ridder MA, Dees J, Schutte HE, van Buuren HR, et al. Endoscopic sphincterotomy and biliary drainage in patients with cholangitis due to common bile duct stones. Am J Gastroenterol. 1995;90(2):233–8.PubMedGoogle Scholar
  50. 50.
    van der Velden JJ, Berger MY, Bonjer HJ, Brakel K, Lameris JS. Percutaneous treatment of bile duct stones in patients treated unsuccessfully with endoscopic retrograde procedures. Gastrointest Endosc. 2000;51(4 Pt 1):418–22.CrossRefGoogle Scholar
  51. 51.
    Minaga K, Kitano M, Imai H, Yamao K, Kamata K, Miyata T, et al. Urgent endoscopic ultrasound-guided choledochoduodenostomy for acute obstructive suppurative cholangitis-induced sepsis. World J Gastroenterol. 2016;22(16):4264–9.CrossRefGoogle Scholar
  52. 52.
    Artifon EL, Takada J, Okawa L, Moura EG, Sakai P. EUS-guided choledochoduodenostomy for biliary drainage in unresectable pancreatic cancer: a case series. JOP. 2010;11(6):597–600.PubMedGoogle Scholar
  53. 53.
    McNabb-Baltar J, Trinh QD, Barkun AN. Biliary drainage method and temporal trends in patients admitted with cholangitis: a national audit. Can J Gastroenterol. 2013;27(9):513–8.CrossRefGoogle Scholar
  54. 54.
    Schiphorst AH, Besselink MG, Boerma D, Timmer R, Wiezer MJ, van Erpecum KJ, et al. Timing of cholecystectomy after endoscopic sphincterotomy for common bile duct stones. Surg Endosc. 2008;22(9):2046–50.CrossRefGoogle Scholar
  55. 55.
    Li VK, Yum JL, Yeung YP. Optimal timing of elective laparoscopic cholecystectomy after acute cholangitis and subsequent clearance of choledocholithiasis. Am J Surg. 2010;200(4):483–8.CrossRefGoogle Scholar
  56. 56.
    Kini S, Kannan U. Effect of bariatric surgery on future general surgical procedures. J Minim Access Surg. 2011;7(2):126–31.CrossRefGoogle Scholar
  57. 57.
    Evans JA, Muthusamy VR, Acosta RD, Bruining DH, Chandrasekhara V, American Society for Gastrointestinal Endoscopy Standards of Practice C, et al. The role of endoscopy in the bariatric surgery patient. Gastrointest Endosc. 2015;81(5):1063–72.CrossRefGoogle Scholar
  58. 58.
    Committee ASoP. The role of endoscopy in the bariatric surgery patient. Surg Endosc. 2015;29(5):1007–17.CrossRefGoogle Scholar
  59. 59.
    Ahmed AR, Husain S, Saad N, Patel NC, Waldman DL, O’Malley W. Accessing the common bile duct after roux-en-y gastric bypass. Surg Obes Relat Dis. 2007;3(6):640–3.CrossRefGoogle Scholar
  60. 60.
    Snauwaert C, Laukens P, Dillemans B, Himpens J, De Looze D, Deprez PH, et al. Laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography in bariatric roux-en-y gastric bypass patients. Endosc Int Open. 2015;3(5):E458–63.CrossRefGoogle Scholar
  61. 61.
    Saleem A, Levy MJ, Petersen BT, Que FG, Baron TH. Laparoscopic assisted ERCP in roux-en-y gastric bypass (RYGB) surgery patients. J Gastrointest Surg. 2012;16(1):203–8.CrossRefGoogle Scholar
  62. 62.
    Bowman E, Greenberg J, Garren M, Guda N, Rajca B, Benson M, et al. Laparoscopic-assisted ercp and eus in patients with prior roux-en-y gastric bypass surgery: a dual-center case series experience. Surg Endosc. 2016;30(10):4647–52.CrossRefGoogle Scholar
  63. 63.
    Williams EJ, Green J, Beckingham I, Parks R, Martin D, Lombard M, et al. Guidelines on the management of common bile duct stones (CBDS). Gut. 2008;57(7):1004–21.CrossRefGoogle Scholar
  64. 64.
    Lacitignola S, Minardi M. Management of common bile duct stones: a ten-year experience at a tertiary care center. JSLS. 2008;12(1):62–5.PubMedPubMedCentralGoogle Scholar
  65. 65.
    Shah JN, Bhat YM, Hamerski CM, Kane SD, Binmoeller KF. Feasibility of nonradiation eus-based ercp in patients with uncomplicated choledocholithiasis (with video). Gastrointest Endosc. 2016;84(5):764–9.CrossRefGoogle Scholar
  66. 66.
    Verma D, Kapadia A, Eisen GM, Adler DG. EUS vs MRCP for detection of choledocholithiasis. Gastrointest Endosc. 2006;64(2):248–54.CrossRefGoogle Scholar
  67. 67.
    Anonymous. British society of gastroenterology (2009) acute jaundice. 2009. www.bsg.org.uk.
  68. 68.
    Anonymous. Ashford and St. Peter’s hospitals NHS Foundation Trust (2011) painless obstructive jaundice. Ambulatory emergency care pathways. Ashford and St. Peter’s Hospitals NHS Foundation Trust. 2011. www.asphnhs.uk.
  69. 69.
    Mitchell J, Hussaini H, McGovern D, Farrow R, Maskell G, Dalton H. The “jaundice hotline” for the rapid assessment of patients with jaundice. BMJ. 2002;325(7357):213–5.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Colorectal/General SurgeryThe Royal Oldham HospitalManchesterUK
  2. 2.Department of General SurgeryThe Pennine Acute Hospitals NHS TrustManchesterUK

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