Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA.
Surg Endosc. 2023 Nov;37(11):8714-8719. doi: 10.1007/s00464-023-10329-x. Epub 2023 Jul 31.
Choledocholithiasis is most often managed in a two-procedure pathway including endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). In contrast, a single-stage, surgery-first approach consisting of LC, cholangiogram, and laparoscopic common bile duct exploration (LCBDE) is associated with reduced hospital stays and equivalent morbidity. Despite this, nationwide referral patterns heavily favor ERCP, obscuring those undergoing ERCP with obstructions amenable to simple intraoperative interventions. We hypothesized that most patients had endoscopic findings consistent with simple sludge or small-to-medium stones, which could have been cleared by basic LCBDE maneuvers.
We retrospectively reviewed 294 patients > 18 years old who underwent preoperative ERCP for the management of suspected choledocholithiasis. Exclusion criteria included: failed ERCP, cholangitis, prior cholecystectomy, patient refusal of surgery, or medical conditions precluding surgical candidacy. Stone size was categorized as small (0-4 mm), medium (5-7 mm), and large (≥ 8 mm).
At the time of ERCP, 37 (20.1%) patients had sludge only, 96 (52.2%) had stones only, 42 (22.8%) had sludge and stones, and 9 (4.8%) had no stones. Of the 138 patients with any stones, 37 (26.8%) had small stones, 41 (29.7%) medium, 43 (31.2%) large, and 17 (12.3%) had uncharacterizable stones. Overall, 74.3% of patients had findings of sludge, stones (0-7 mm), or negative ERCP.
The majority of patients who underwent preoperative ERCP for suspected choledocholithiasis had findings that are amenable to simple intraoperative interventions. In fact, over a quarter of the patients had a negative ERCP, sludge, or small stones which would likely be cleared by flushing/glucagon precluding any further instrumentation. While large stones may require more advanced techniques, this represents a small percentage of patients. Surgery-first management for suspected choledocholithiasis can offer an efficient alternative for the majority of patients.
胆总管结石的治疗方法通常采用两阶段途径，包括内镜逆行胰胆管造影（ERCP）后行腹腔镜胆囊切除术（LC）。相比之下，一期手术、先手术的方法包括 LC、胆管造影和腹腔镜胆总管探查术（LCBDE），与缩短住院时间和等效的发病率相关。尽管如此，全国范围内的转诊模式严重偏向 ERCP，掩盖了那些接受 ERCP 治疗的、适合简单术中干预的阻塞患者。我们假设大多数患者的内镜检查结果符合单纯性淤渣或小至中等大小的结石，这些结石可以通过基本的 LCBDE 操作清除。
我们回顾性分析了 294 例年龄大于 18 岁的因疑似胆总管结石而行术前 ERCP 的患者。排除标准包括：ERCP 失败、胆管炎、既往胆囊切除术、患者拒绝手术或存在手术禁忌证的医疗状况。结石大小分为小（0-4mm）、中（5-7mm）和大（≥8mm）。
在 ERCP 时，37 例（20.1%）患者仅有淤渣，96 例（52.2%）仅有结石，42 例（22.8%）既有淤渣又有结石，9 例（4.8%）无结石。在 138 例有任何结石的患者中，37 例（26.8%）为小结石，41 例（29.7%）为中等大小结石，43 例（31.2%）为大结石，17 例（12.3%）为无法确定大小的结石。总体而言，74.3%的患者 ERCP 结果为淤渣、结石（0-7mm）或阴性。
大多数因疑似胆总管结石而行术前 ERCP 的患者的检查结果可通过简单的术中干预来处理。事实上，超过四分之一的患者 ERCP 结果为阴性、淤渣或小结石，通过冲洗/胰高血糖素处理可能会清除这些结石，从而无需进一步的器械操作。虽然大结石可能需要更先进的技术，但这只占患者的一小部分。对于疑似胆总管结石的患者，先手术治疗可以为大多数患者提供一种有效的替代方法。
