Ammori B J, Birbas K, Davides D, Vezakis A, Larvin M, McMahon M J
Division of Surgery, University of Leeds and Leeds Institute for Minimally Invasive Therapy, The General Infirmary, Great George Street, Leeds, LS1 3EX, England.
Surg Endosc. 2000 Dec;14(12):1123-6. doi: 10.1007/s004640000146.
The detection of small and often asymptomatic gallbladder calculi within the bile duct at intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) frequently poses a management dilemma. Therefore, we set out to compare the outcomes and costs of two management strategies for small stones that remain in the bile duct after LC-routine postoperative endoscopic retrograde cholangiopancreatography (ERCP) vs observation alone with "on-demand" ERCP.
We studied 70 patients with bile duct stones among 922 consecutive patients who underwent LC between 1990 and 1997. Data were collected prospectively. Bile duct calculi were detected in 70 of 705 patients (9.9%) with successful IOC. Of these, 44 patients had large calculi (> or =5 mm in diameter) and were subjected to a laparoscopic common bile duct exploration. The remaining 26 patients had small calculi (<5 mm in diameter); four of them had undergone preoperative endoscopic sphincterotomy and duct clearance and were therefore excluded from analysis. Patients with small duct calculi were assigned, according to individual surgeon policy, to either routine postoperative ERCP (group A, n = 8) or observation (group B, n = 14). ERCP was reserved for those who become symptomatic. The two groups were comparable for age and sex distribution.
No complications developed during the follow-up period in patients assigned to observation, although four became symptomatic and underwent ERCP. In group A, ERCP demonstrated a clear biliary tree in four patients and bile duct calculi in three patients; it failed in one patient. In group B, ERCP demonstrated a clear bile duct in one patient and bile duct calculi in two patients; it also failed in one patient. Endoscopic sphincterotomy and duct clearance were achieved in all patients with demonstrable bile duct calculi at ERCP. There was no morbidity or mortality associated with ERCP. The overall hospital stay was significantly longer in group A than in group B (median 5 vs 1.5 days; p = 0.011); however, the number of outpatient clinic visits was significantly greater in group b (median 3 vs 5.5, p = 0.011). The mean hospital costs, including the costs of hospital stay, readmissions, ERCP, and follow-up, were significantly greater in group A than in group B (mean pound2669 vs pound1508, p = 0.008).
A "wait and see" policy of observation alone for patients with small bile duct calculi detected at IOC during LC appears to be safe, and it is more cost-effective than routine postoperative ERCP. ERCP should be reserved for post-LC patients who become symptomatic.
在腹腔镜胆囊切除术（LC）期间的术中胆管造影（IOC）过程中，常常会检测到胆管内小的且通常无症状的胆囊结石，这常常给处理带来难题。因此，我们着手比较两种处理策略对于LC术后胆管内残留小结石的效果和成本——常规术后内镜逆行胰胆管造影（ERCP）与仅观察并“按需”进行ERCP。
我们研究了1990年至1997年间连续接受LC的922例患者中的70例胆管结石患者。数据是前瞻性收集的。在705例IOC成功的患者中有70例（9.9%）检测到胆管结石。其中，44例患者有大结石（直径≥5mm），并接受了腹腔镜胆总管探查。其余26例患者有小结石（直径<5mm）；其中4例患者术前已接受内镜括约肌切开术和胆管清理，因此被排除在分析之外。根据个别外科医生的策略，胆管小结石患者被分配至常规术后ERCP组（A组，n = 8）或观察组（B组，n = 14）。ERCP仅用于出现症状的患者。两组在年龄和性别分布上具有可比性。
观察组患者在随访期间未出现并发症，尽管有4例出现症状并接受了ERCP。在A组中，ERCP显示4例患者胆管树清晰，3例患者有胆管结石；1例患者ERCP失败。在B组中，ERCP显示1例患者胆管清晰，2例患者有胆管结石；1例患者ERCP也失败。所有在ERCP中显示有胆管结石的患者均成功进行了内镜括约肌切开术和胆管清理。ERCP未导致任何发病或死亡。A组的总体住院时间显著长于B组（中位数5天对1.5天；p = 0.011）；然而，B组的门诊就诊次数显著更多（中位数3次对5.5次，p = 0.011）。A组的平均住院费用，包括住院、再次入院、ERCP和随访费用，显著高于B组（平均2669英镑对1508英镑，p = 0.008）。
对于在LC术中IOC检测到胆管小结石的患者，仅采用“观察等待”策略似乎是安全的，并且比常规术后ERCP更具成本效益。ERCP应仅用于LC术后出现症状的患者。
