Therapeutic Approact in Patients with Asymptomatic Choledocholithiasis
The purpose of this study was to explore the possibilities of modern laparoscopic techniques to identify and remove the stones from the bile duct in patients with asymptomatic choledocholithiasis.
Material and Methods. During the period from 2003 to 2010 in the clinic there were operated 2488 patients with calculous cholecystitis. One group of surgeons during this period completed 1256 laparoscopic cholecystectomies. The second group of surgeons during laparoscopic cholecystectomy in each suspect case produced a revision of the bile duct and detected stones with their recovery. They produced 1232 laparoscopic cholecystectomy. During the operation, the patients who had a common bile duct expansion more than 9 mm, the cystic duct of more than 3 mm, as well as the presence of small stones in the gallbladder, necessarily performed intraoperative cholangiography. A number of patients for diagnostic purposes fibrocholangiography. Only the second group of patients produced intraoperative cholangiography in 276 patients and 148 patients fibrocholangioskopy. Of the 574 patients in whom surgery was performed during the diagnosis of bile duct stones were found in 165 patients. They were out before the operation are clear signs of choledocholithiasis. External drainage through the cystic duct was carried out in cases of cholangitis, the presence of small stones in the common bile duct, biliary pancreatitis. Long-term results in operated patients was studied in terms of 3, 6, 12, 24, 32, 48 months, according to a special questionnaire, ultrasound studies and biochemical analyzes of blood.
Results and Discussion. Mean age, gender composition, the presence of comorbidity were similar in both groups. The frequency of biliary pancreatitis and transient jaundice was slightly higher in group B, where interventions were made by the ducts. Group A when performing laparoscopic cholecystectomy conversion performed in 14 patients (1.1 %). Postoperative complications in пroup A were observed in 42 patients (3.3 %), Including from 5 after conversion. Purulent-septic complications were in 17 patients, intra-abdominal bleeding — in 3, bile leakage on drainage in 18 patients, postoperative pneumonia — in 3 patients. Reoperations were performed in 7 patients (0.6 %). Patients in the group B, revision of bile duct was performed in 424 (34.4 %) patients, stones were found in 165 (13.4 %) patients. 40 patients to remove stones from the duct through the cystic duct failed. Outside choledochal drainage was performed in only 46 patients (27.9 %) of 165 patients. Total complications in group B was observed in 19 patients (1.5 %). Residual stones were found in 23 (2.4 %) patients in group A, and only in 4 patients (0.4 %) patients in group B.
In most hospitals prefer to use a two-stage treatment: in the first stage perform ERCP and endoscopic papillotomy with extraction of stones, and then after a time produce a laparoscopic cholecystectomy. At the same time, low-symptom choledocholithiasis this tactic leads to unnecessary endoscopic interventions on a large duodenal papilla, which increases the rate of complications requiring surgery achievements of modern solutions to all problems, ie removal of the gallbladder with stones and remove the stones from the bile duct, during the same operation.
When comparing the two treatment tactics proved that the use of laparoscopic techniques of revision bile duct itself although increases duration of operation, nevertheless do not lead to an increase in the number of postoperative complications or prolongation of hospitalization.
Conclusions. The optimum method of identifying oligosymptomatic choledocholithiasis is revision of the bile duct during laparoscopic cholecystectomy. This tactic does not increase the number of postoperative complications and increased length of hospital treatment.
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