Department of Surgery, Far Eastern University Dr. Nicanor Reyes Medical Foundation Medical Center, Manila, Philippines.
Surg Endosc. 2018 Feb;32(2):770-778. doi: 10.1007/s00464-017-5739-y. Epub 2017 Jul 21.
Laparoscopic cholecystectomy (LC) for symptomatic gallstone disease is one of the most common surgical procedures. Concomitant common bile duct (CBD) stones are detected with an incidence of 4-20% and the ideal management is still controversial. The frequent practice is to perform endoscopic sphincterotomy pre-operatively (POES) followed by LC, to allow subsequent laparoscopic or open exploration if POES fails. However, POES has shown different drawbacks such as need for two hospital admissions, need of two anesthesia inductions, higher rate of pancreatitis, and longer hospital stay. Hence, an intra-operative endoscopic sphincerotomy (IOES) has been proposed.
To compare the 1 stage laparoscopic cholecystectomy (LC) combined with IOES versus 2-stage POES followed by LC for the management of pre-operatively known cholecystocholedocholithiasis.
The search terms bile duct stones/calculi, ERCP, endoscopic sphincterotomy, laparoendoscopic rendezvous (LERV), and laparoscopic ductal clearance/choledochotomy/exploration were used. A comprehensive hand-based search of reference lists of published articles and review articles was performed to ensure inclusion of all possible studies and exclude duplicates.
RCTs comparing 1 stage LC combined with IOES versus 2-stage POES followed by LC for the management of pre-operatively known cholecystocholedocholithiasis in adults.
DATA COLLECTION & ANALYSIS: Three reviewers assessed trial quality and extracted the data. Data were entered in revman version 5.3. The trials were grouped according to the outcome measure assessed such as success rate of CBD stone clearance, incidence of pancreatitis, overall morbidity, and length of hospital stay.
A total of 629 patients in 5 RCTs met the inclusion criteria. The success rate of CBD clearance (IOES = 93%, POES = 92%) was the same in both groups (OR 1.34; 95% CI 0.45-0.97; p = 0.60). Findings showed that IOES was associated with less pancreatitis (0.6%) than POES (4.4%) (OR 0.19; 95% CI 0.06-0.67; p = 0.01; I = 43%). The incidence of overall morbidity was lower in the IOES group (6%) than the POES group (11%) (OR 0.54; 95% CI 0.31-0.96; p = 0.03; I = 20%). The mean days of hospital stay for IOES group (M = 3.52, SD = 1.434, N = 5) was significantly less than the POES group (M = 6.10, SD = 2.074, N = 5), t(8) = 2.29, p <= 0.051.
IOES is at par with two-stage POES in terms of CBD clearance, with less incidence of post-operative pancreatitis, overall morbidity, and less hospital stay.
腹腔镜胆囊切除术（LC）治疗有症状的胆囊结石病是最常见的外科手术之一。胆总管（CBD）结石的发生率为 4-20%，其理想的治疗方法仍存在争议。目前的常见做法是在术前（POES）行内镜下括约肌切开术，然后再行 LC，如果 POES 失败，再行腹腔镜或开放性探查。然而，POES 存在一些缺点，如需要两次住院，需要两次麻醉诱导，胰腺炎发生率较高，住院时间较长。因此，提出了术中内镜下括约肌切开术（IOES）。
比较 1 期 LC 联合 IOES 与 2 期 POES 后 LC 治疗术前已知的胆囊胆管结石的疗效。
使用了胆管结石/结石、ERCP、内镜下括约肌切开术、腹腔镜内镜会师术（LERV）和腹腔镜胆管清除术/胆管切开术/探查术等检索词。通过全面的手工检索已发表文章和综述文章的参考文献列表，以确保纳入所有可能的研究，并排除重复研究。
比较 1 期 LC 联合 IOES 与 2 期 POES 后 LC 治疗术前已知胆囊胆管结石的 RCTs，纳入成人患者。
三名评审员评估试验质量并提取数据。数据输入 revman 版本 5.3。根据评估的结局指标，如 CBD 结石清除成功率、胰腺炎发生率、总发病率和住院时间，将试验进行分组。
共有 5 项 RCT 中的 629 名患者符合纳入标准。两组 CBD 清除成功率（IOES=93%，POES=92%）相同（OR 1.34；95%CI 0.45-0.97；p=0.60）。研究结果表明，IOES 相关的胰腺炎发生率（0.6%）低于 POES（4.4%）（OR 0.19；95%CI 0.06-0.67；p=0.01；I²=43%）。IOES 组的总发病率（6%）低于 POES 组（11%）（OR 0.54；95%CI 0.31-0.96；p=0.03；I²=20%）。IOES 组的平均住院天数（M=3.52，SD=1.434，N=5）明显短于 POES 组（M=6.10，SD=2.074，N=5），t（8）=2.29，p<=0.051。
IOES 在 CBD 清除率方面与两阶段 POES 相当，术后胰腺炎、总发病率和住院时间均较低。
