El Nakeeb Ayman, El Geidie Ahmed, El Hanafy Ehab, Atef Ehab, Askar Waleed, Sultan Ahmad M, Hamdy Emad, El Shobary Mohamed, Hamed Hosam, Abdelrafee Ahmed, Zeid Mostafa Abu
Gastroenterology Surgical Center, Mansoura University , Mansoura, Egypt .
J Laparoendosc Adv Surg Tech A. 2016 Mar;26(3):161-7. doi: 10.1089/lap.2015.0493. Epub 2016 Feb 1.
Management of common bile duct stones (CBDS) in patients with borderline CBD presents a surgical challenge. The aim of this study was to compare conservative treatment with endoscopic stone extraction for the treatment of borderline CBD with stones.
This prospective randomized controlled trial includes patients with CBDS in borderline CBD (CBD <10 mm) associated with gallbladder stones who were treated with conservative treatment or endoscopic stone extraction followed by laparoscopic cholecystectomy (LC) and intraoperative cholangiogram (IOC). The primary outcome was successful CBD clearance. The secondary outcomes were the overall complications, cost, and hospital stay.
LC and IOC revealed complete clearance of CBDS in 48 (96%) cases in the endoscopic retrograde cholangiopancreatography (ERCP) group (52% of patients by ERCP, and 44% of patient passed the stone spontaneously), and in the remaining two patients, the CBDS was removed by transcystic exploration. In the conservative group, LC and IOC revealed complete clearance of CBDS in 90% of cases, and in the remaining 10% of patients, the CBDS was removed by transcystic exploration. Post-ERCP pancreatitis (PEP) is noticed significantly in the ERCP group (2 [4%] versus 8 [16%]; P = .04). The average net cost was significantly higher in the ERCP group. Recurrent biliary symptoms developed significantly in the ERCP group after 1 year (10% versus 0%; P = .02) in the form of recurrent cholangititis and recurrent CBDS.
Management of CBDS in patients with borderline CBD represents a surgical challenge. Borderline CBD increases the technical difficulty of ERCP and increases the risk of PEP. Conservative management of CBDS in borderline CBD not only avoids the risks inherent in ERCP and unnecessary preoperative ERCP, but it is also effective in clearing CBDS. The hepatobiliary surgeon should consider a conservative line of treatment in CBDS in borderline CBD in order to decrease the cost and avoid unnecessary ERCP.
对于胆管直径临界的患者，胆总管结石（CBDS）的处理是一项手术挑战。本研究的目的是比较保守治疗与内镜下取石术治疗胆管直径临界且伴有结石的情况。
这项前瞻性随机对照试验纳入了胆管直径临界（胆管直径<10毫米）且伴有胆囊结石的胆总管结石患者，这些患者接受了保守治疗或内镜下取石术，随后进行腹腔镜胆囊切除术（LC）和术中胆管造影（IOC）。主要结局是胆总管结石成功清除。次要结局包括总体并发症、费用和住院时间。
在内镜逆行胰胆管造影（ERCP）组中，LC和IOC显示48例（96%）患者的胆总管结石完全清除（52%的患者通过ERCP清除，44%的患者结石自行排出），其余2例患者通过经胆囊探查清除胆总管结石。在保守治疗组中，LC和IOC显示90%的病例胆总管结石完全清除，其余10%的患者通过经胆囊探查清除胆总管结石。ERCP组中术后胰腺炎（PEP）的发生率显著高于保守治疗组（2例[4%]对8例[16%]；P = 0.04）。ERCP组的平均净费用显著更高。1年后，ERCP组复发性胆道症状的发生率显著高于保守治疗组（10%对0%；P = 0.02），表现为复发性胆管炎和复发性胆总管结石。
胆管直径临界患者的胆总管结石处理是一项手术挑战。胆管直径临界增加了ERCP的技术难度，并增加了PEP的风险。胆管直径临界的胆总管结石保守治疗不仅避免了ERCP固有的风险和不必要的术前ERCP，而且在清除胆总管结石方面也是有效的。肝胆外科医生在胆管直径临界的胆总管结石治疗中应考虑保守治疗方案，以降低费用并避免不必要的ERCP。
