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POSSIBILITIES OF ONE-STAGE MANAGEMENT OF COMPLICATED CHOLELITHIASIS WITH USE OF INTRAOPERATIVE ANTEGRADE ENDOSCOPIC PAPILLOSPHINCTEROTOMY IN URGENT SURGERY
Alekseev N.A., Baranov A.I., Snigirev Yu.V., Snigirev A.Yu.
Novokuznetsk City Clinical Hospital
No.5,
Novokuznetsk State Medical Extension Course Institute – the Branch of Russian Medical Academy of Continuous
Professional Education, Novokuznetsk, Russia
Despite
of great achievements and new technologies in surgical management of
complicated form of cholelithiasis, the importance of this disease is still
actual. According to results of examinations, cholelithiasis is identified in
8-25 %, and in 30 % in older persons. In acute cholecystitis, the incidence of cholelithiasis
reaches 35 % [1, 2].
The
improvement in low invasive techniques, which minimize the surgical trauma,
allowed extending the possibilities of surgical correction of pathology [3, 4].
However in this case, the realization of correction of abnormality of biliary
ducts requires for participation of physicians of several related specialties
(surgeon, endoscopist, radiologist). According to the literature data, the
preference is given to multi-stage technique for surgical management of
complicated cholelithiasis, when the first stage means the retrograde
endoscopic papillosphincterotomy (REPST) with transpapillary manipulations, the
second stage – cholecystectomy [5, 6]. At the same time, realization of
retrograde interventions is accompanied by complications (bleeding,
retroduodenal perforation, acute pancreatitis, acute cholangitis, septic shock)
from 1 to 19 % [7, 8, 9]. Despite the high amount of different variants of
surgical management of cholecystocholedocholithiasis (one- and two-staged
treatment), the advantages have not been properly studied, and the most optimal
technique is unknown, that is important for urgent patients [10, 11, 12].
Objective – to evaluate the effectiveness of performing intraoperative antegrade
endoscopic papillosphincterotomy in one-step surgical management of cholecystocholedocholithiasis
and two-step management with retrograde endoscopic papillosphincterotomy for
emergency patients.
MATERIALS AND METHODS
In 2010-2015, 624 patients
(women – 72.3 %, men – 27.7 %, mean age – 61.3 ± 13.9) received the surgery.
The patients were urgently admitted with the complicated form of cholelithiasis.
The one-stage treatment of cholecystocholedocholithiasis was conducted on the
basis of clinical data, which indicated the complicated forms of
cholelithiasis, and laboratory examination. The main technique of
cholecystocholedocholithiasis diagnostics was ultrasonic examination (USE).
Also the results of fibrogastroduodenoscopy (FGDS) were considered.
The
one-stage surgical management was conducted for 188 (30.1 %) patients who could
not receive transpapillary manipulations due to organic pathology (duodenal
deformation, mass lesions in region of major duodenal papilla (MDP), fixed
concrement in distal part of choledoch duct), previous gastric resection by
B-II. Also the one-stage management was used for patients with
scar-inflammatory changes in gall bladder and hepatoduodenal ligament. For such
patients, the surgical treatment was conducted with the mini-approach or
laparotomy approach.
Two-stage
surgical management was used for 436 (69.9 %) patients with the inflammation
signs (cholangitis, pancreatitis) diagnosed with the clinical and laboratory
indices, and with ultrasonic data of multiple choledolithiathis, big stones in
biliary duct, and significant (more 13 mm) increase in diameter of hepaticocholedochus.
Intrasurgical
antegrade endoscopic papillosphincterotomy (ISAEPST) is not so popular as REPST
according to small number of reports and low amount of described interventions,
with limited number of publications [13, 14, 15]. Since the increase in
bilirubin over 100 µmol/l elevates the risk of identification of the block of
distal part of choledoch duct and big stones, the use of single-stage technique
with ISAEPST was limited by this index.
Chronic
calculous cholecystitis (CCC), choledolithiasis and obstructive jaundice were
the most frequent pathology in the study group. The rarest form of
cholecystocholedocholithiasis was choledocystocholedocheal fistula. The table 1
shows the nosological forms of abnormality.
Таблица 1. Нозологические формы холецистохоледохолитиаза
Table 1. Nosological
forms of cholecystocholedocholithiasis
|
Forms of cholelithiasis |
(n = 624) |
|
|
Abs. |
% |
|
|
Chronic calculous cholecystitis. Choledocholithiasis. Obstructive jaundice. |
238 |
38.2 |
|
Chronic calculous cholecystitis. Choledocholithiasis. Major duodenal papilla stenosis. Obstructive jaundice. |
108 |
17.3 |
|
Acute cholecystitis. Choledocholithiasis. Cholangitis. Obstructive jaundice. |
76 |
12.2 |
|
Acute cholecystitis. Choledocholithiasis. Obstructive jaundice. |
65 |
10.4 |
|
Chronic calculous cholecystitis. Choledocholithiasis. Cholangitis. Obstructive jaundice. |
44 |
7.0 |
|
Acute cholecystitis. Choledocholithiasis. |
39 |
6.3 |
|
Chronic calculous cholecystitis. Major duodenal papilla stenosis. Obstructive jaundice. |
29 |
4.6 |
|
Mirizzi syndrome. Obstructive jaundice. |
25 |
4.0 |
Among
urgently admitted patients with cholecystocholedocholithiasis, obstructive
jaundice was identified in 585 (93.8 %) cases. It was noted that the duration
of jaundice up to 7 days was in 394 patients (63.1 %), 7-14 days – in 140 (22.4
%) patients, more than 2 weeks – 90 (14.5 %).
ASA (American Society of Anesthesiologists) criteria
were used for estimation of degree of surgical and anesthesiological risk. The
distribution into categories was presented as follows: ASA
I
– 71 (11.4 %), ASA II – 346 (55.4 %), ASA
III
– 190 (30.5 %) and ASA
IV
– 17 (2.7 %).
Correction
of pathology of extrahepatic biliary ducts was conducted with the combined
method of endoscopic interventions depending on an identified pathology:
ISAEPST, REPST in various combinations, lithoextraction, mechanic biliary lithotripsy
(MBL), transpapillary draining (nasobiliary draining (NBD), biliary duct
stenting). The non-common techniques of papillosphincterotomy were used in
identification of peripapillary diverticle, stone impacted into MDP, full blocking
of distal part of biliary duct. Depending on sizes, number of stones and
presence of cholangitis, the further treatment was defined.
The patients with
cholecystocholedocholithiasis received the whole range of surgical approaches:
low invasive interventions (laparoscopic cholecystectomy (LCE), minicholecystectomy
(MCE), standard laparotomy (SCE). Intrasurgical cholangiography (ISCG) was
conducted in 100 % of cases.
In compliance with requirements of biomedical ethics,
the informed consent was received for all participating patients. The study
protocol was approved by the ethical committee of Novokuznetsk State
Medical Extension Course Institute.
Descriptive
statistics was used for systematization, visual presentation of material in
view of charts and tables and their quantitative description. The quantitative
data was presented as the mean (M), standard deviation (m). The qualitative
sign were presented as absolute values (n) and percentage (%). The
non-parametrical methods were used for estimation of statistical significance
of intergroup differences with use of Mann-Whitney U-test. P ≤ 0.05 was considered as critical level of
significance in testing the statistical hypotheses.
RESULTS AND DISCUSSION
The laparoscopic approach was main in
one-stage management of cholecystocholedocholithiasis.
It was used for 157 (83.5 %) patients. 92 patients received LCE, ISAEPST and
removal of biliary duct concrements. External draining of biliary duct
completed the realization of LCE with ISAEPST in 22 patients; it was associated
with the fact that some events of inflammation in biliary duct, big concrements
and their high number were found during transpapillary interventions, with high
hyperbilirubinemia.
During one-stage management with LCE
and ISAEPST, 27 (14.4 %) patients required for MBL. Presurgical ultrasonic examination
showed the biliary duct wider 21 mm in 21 patients. Totally, 47 patients showed
the presurgical extension of common biliary duct of 12 mm and more. Therefore,
the biliary duct diameter > 12 mm, according to presurgical USE, supposed MBL in 44.6 %.
Conversion to the mini-approach was
realized for identified intrasurgical Mirizzi syndrome in 2 patients. One
patient had laparotomy and bleeding arrest from MDP, which appeared due to
technical difficulties during ISAEPST (a big concrement in biliary duct).
Mini-approach in one-stage management
was used for 16 (8.5 %) patients. ISAEPST in combination with MCE was conducted
for 6 patients. After surgery with IAEPST, 5 patients received external
draining of biliary ducts. 3 patients required for choledochojejunostomy from
mini-laparotomy approach. It was associated with identification of big
concrements in hepatic choledoch duct, cholangitis and hyperbilirubinemia at
the background of significant (more 20 mm) extension of gall bladder. These
patients had no endoscopic approach to MDP. ISAEPTS and separation of
bladder-choledoch fistula was conducted in 2 cases.
15 patients (8 %) received the
traditional laparotomy approach in one-stage management. 6 patients received
laparotomy, cholecystectomy and ISAEPST. 4 patients required for completion of hepaticocholedochus
with external draining. 2 patients required for choledocholithotomy,
choledochoscopy with choledochojejunostomy for inflammatory infiltrate in
subhepatic space at the background of absent approach to MDP. ISAEPST from
laparotomy approach was conducted at the background of Mirizzi syndrome for 3
patients.
26
patients received ISAEPST from mini- and laparotomy approaches at the
background of evident inflammatory-infiltrative process in the region of
duodenum, gall bladder and hepaticoduodenal ligament. This situation did not
require for duodenotomy and choledochotomy, and, as result, did not require for
minimization of perisurgical complications.
Two-stage
surgical management of cholecystocholedocholithiasis was urgently used for 436
patients. 330 (75.7 %) patients received the first stage surgical management
during the first day. They had the clinical signs of acute blocking of distal
part of choledochus, high indices of hyperbilirubinemia, cholangitis. In 106 (24.3
%) cases, the first stage was realized after presurgical preparation
(correction of water-electrolytic disorders, coagulopathy).
At
the first stage, REPST with lithoextraction was conducted for 190 (43.6 %)
patients. 130 (29.8 %) patients required for MBL. The need for bile duct
stenting through MDP appeared in 112 (25.7 %) patients, when multiple
choledolithiasis, inflammatory stenosis of the common bile duct, bile duct
concrements difficult for surgical removal, as well as retrograde
cholangiography were identified. 80 (18.3 %) patients needed for NBD. Usually,
NBD was realized in presence of events of purulent cholangitis, need for
multi-stage treatment, hepaticocholedochus stenosis with inflammatory
infiltrate and severe cholestasis. NBD decreased the necessity for additional
retrograde revision with aim of receiving of information on abnormal changes in
choledochus and monitoring of characteristics and volume of bile. At the first
stage, 192 (44 %) patients required for transpapillary draining of hepaticocholedochus
(NBD, stenting).
Almost
a half (n = 215, 49.3 %) patients with two-stage management had the recurrent
retrograde transpapillary interventions. When estimating the diameter of
choledochus among 215 patients with recurrent retrograde manipulations, 171
(79.5 %) patients had the presurgical ultrasonic data of choledochus diameter
of 12 mm and more. Totally, the diameter of 12 mm and more was diagnosed in 284
(65.1 %) patients with two-stage management. Moreover, most of them needed for
recurrent retrograde interventions (60.2 %). The identified findings (i.e.
choledochus diameter ≥ 12 mm) can be a prediction criterion for recurrent
surgical interventions.
After
retrograde revision at the first stage, the second stage was immediately
planned for 47 (10.8 %) patients due to inefficiency of endoscopic retrograde
removal of identified pathology.
At
the second stage, as well as in one-stage treatment, the preference was given
to low-invasive techniques of surgical intervention. LCE was conducted in more
than in half of cases – 238 (54.6 %) patients. So, peroral cholecystography
(PCG) was the obligatory component of intrasurgical diagnosis which identified
residual concrements in bile ducts in 31 (13 %) patients. This pathology was
removed intrasurgically by means of retrograde endoscopic removal of
concrements under control of duodenoscope. 2 patients required for
choledochotomy and removal of concrement since the concrement was fixed in the
choledochus. 17 patients required for external draining of choledochus.
The
need for transition to the mini-approach appeared in 2 patients since infiltrative
changes in region of common bile duct at the background of Mirizzi syndrome
were diagnosed during surgery. The intrasurgical inflammatory destructive
infiltrate in subhepatic space at the background of acute cholecystitis was the
reason for TCE in 2 patients.
The
mini-approach after the first stage was used for 137 (31.6 %) patients with
cholecystocholedocholithiasis. Cholecystectomy from the mini-approach was
conducted for 77 patients. Moreover, during surgery after PCG, residual
choledolithiasis was identified in 8 patients. It was corrected in retrograde
manner during the intervention.
MCE
was used for 12 patients with Mirizzi syndrome. After separation of the fistula
and removal of concrements from biliary duct, choledochoscopy was obligatory.
The intervention was completed with hepaticocholedochus plasty (n = 8) or with
formation of choledochoduodenoanastomosis (n = 4).
Dilatation
of hepatocholedochus more than 20 mm at the background of multiple big
concrements was the cause of choledochoduodenostomy in 10 patients. MCE was
combined with choledochotomy and lithoextraction and choledochoscopy in 38
patients.
The
inflammatory destructive changes in acute cholecystitis required for transition
to the laparotomy approach in 1 patient since differentiation of tissues from
the mini-approach was difficult.
Traditional
surgical approach was planned for 61 (13.8 %) patients after the first stage.
Cholecystectomy was performed for 26 patients. Intrasurgically, residual choledocholithiasis
was diagnosed in 7 patients. The concrements were removed in retrograde manner
with use of the duodenoscope.
Choledocystoledocheal
fistula was the cause of TCE in 8 patients. In all these patients, choledochoscopy
was the intrasurgical medicodiagnostic standard. Since the patency of the
distal part was restored after the first stage, the final stage included the
hepatocholedochus plasty with T-shaped drain for 7 patients. One patient had
the formed biliodigestive conjunction.
The big diameter of hepatocholedochus and big multiple
choledolithiathis were the reasons for formation of anastomosis in 7 patients.
20 patients required for external draining of hepaticocholedochus at the final
stage.
After
the first stage, intrasurgically, after PCG, the biliary duct concrements were
diagnosed in 46 (10.6 %) patients. The analyzed group of the patients showed
that normalization of clinicolaboratory values had happened by the days 2-4
after one-stage management, and by the days 4-8 after two stages (the table 2).
Таблица
2. Длительность нормализации клинико-лабораторных
показателей после оперативного лечения, М ± m
Table 2. Duration of
normalization of clinical and laboratory values after surgical treatment, М ± m
|
Values |
Number of days for single-step management |
Number of days for two-step management |
||||
|
Laparoscopic cholecystectomy, |
Minilaparotomy cholecytectomy, |
Standard cholecytectomy, |
Laparoscopic cholecystectomy, |
Minilaparotomy cholecytectomy, |
Standard cholecytectomy, |
|
|
Body temperature, °С |
2.3 ± 0.64 |
2.4 ± 1.1 |
3.5 ± 1.29 |
4.3 ± 1.26* |
4.8 ± 1.64** |
6.1 ± 1.79*** |
|
LII |
2.2 ± 0.51 |
3.6 ± 0.72 |
3.6 ± 0.87 |
6.2 ± 0.78* |
7.5 ± 1.3** |
7.5 ± 1.16*** |
|
Amylase, U/l |
- |
- |
- |
3.4 ± 0.88 |
3.6 ± 0.65 |
3.9 ± 0.70 |
Note: * – difference between values for laparoscopic cholecystectomy (p < 0.05); ** – difference between values for minilaparotomy cholecytectomy (p < 0.05); *** – difference between values for standard cholecytectomy; LII – leukocytal intoxication index.
Estimating the efficiency of
surgical management of cholecystocholedocholithiasis, we can see that the low
invasive approaches result in faster posttraumatic rehabilitation of patients,
considering the time course of decrease in hyperthermia and LII. This trend was
noted both in one- and two-staged management. One should note that patients
with one-stage management had less severe basic condition.
For
objective estimation, all postsurgical complications were distributed into two
categories: 1) associated with manipulations for MDP; 2) associated with a
surgical approach.
In
urgent situation with one-stage correction of pathology of biliary ducts, the
complications of the first category relating to ISAEPST and transpapillary
manipulations were noted in 1.1 % (n = 2) of cases (1 – bleeding from MDP; 1 –
acute pancreatitis without need for surgical correction).
The
use of two-stage surgical management was accompanied by the complications of
the first category after REPST and transpapillary intraductal interventions in 3
% (n = 13):
-
postpapillotomic bleeding, which was noted in 5 (1.15 %) patients; 1 patient
required for realization of traditional laparotomy, hemostasis due to
inefficiency of combined pharmacological and endoscopic hemostasis;
- acute pancreatitis caused by endoscopic retrograde
manipulations for MDP were identified in 5 (1.15 %) patients. 4 patients
reached the positive time course by means of intensive care (4.9 ± 1.2 days).
One patient received laparotomy because of progression of the acute process;
-
2 (0.46 %) patients received the fixation of basket forceps on the intraductal
concrement. This problem was solved through the traditional laparotomy
approach;
-
1 (0.23 %) patient required for laparotomy due to retroduodenal perforation.
The
transitory increase in blood amylase without signs of acute pancreatitis after
antegrade interventions for MDP was registered in 1.06 % of cases, after
retrograde interventions – in 13.07 %.
Therefore,
we registered the significant decrease in complications relating to
manipulations with MDP in the antegrade approach – 1.1 % vs. 3 % after
retrograde one.
The
approach-related complications (category 2) were in patients who received the
one-stage treatment (5.8 %): complications were diagnosed 2 patients in laparotomy;
the mini-approach was used for 3 patients; complications were registered in 6
patients after traditional laparotomy. The high amount of complications of the
second category after one-stage correction of cholecystocholedocholithiasis
from the mini-approach and the traditional laparotomy approach were determined
by surgical injury (the number of wound complications increased with increasing
size of an incision) and by the fact that choice of these approaches was often
determined by contraindications for overlay of pneumoperitoneum owing to severe
basic condition of the patient which was caused by purulent septic, cholestatic
complications of cholecystocholedocholithiasis, and as a rule, concurrent
decompensated somatic pathology.
The
patients with two-stage management showed the complications of the second
category in 3.7 % of cases at the second stage. These patients showed the high
amount of complications of the approach along with extending the surgical
approach. So, for LCE, the complications were fixed in 3 patients, for MCE – in
5, in traditional laparotomy – in 8.
The
lower amount of complications in two-stage management (4.2 % as compared to
one-stage management) is explained by the fact that the patients were at the
moment after correction of acute events and jaundice at the second stage.
Among
all patients, 5 (0.8 %) lethal outcomes were registered: 2 patients with
one-stage treatment, 3 – with two-stage one. In both groups, the lethal cases
were not associated with techniques of treatment. The patients were in the
group 4 according to ASA and they had severe main and concurrent abnormalities.
3
patients had some situations, which had required for conversion of the
laparoscopic approach in one-stage management: 1 patient received laparotomy,
bleeding arrest from MDP after ISAEPST; 2 patients received the mini-approach
for cholecystocholedocheal fistula. The similar situations requiring for
conversion of the approach at the two-stage management were observed in 5
patients: 2 patients received the mini-approach for cholecystocholedocheal
fistula and scar-adhesion changes in gall bladder and hepatoduodenal ligament.
3 patients received the traditional laparotomy due to inflammatory infiltrate
at the background of acute destructive cholecystitis and, as result, difficulties
in tissue differentiation.
Also,
estimating the treatment results, we noted that the use of one-stage management
allowed deceasing the time of stay in ICU and in the hospital (the table 3).
The use of ISAEPST was efficient for 29.3 % of patients.
Таблица 3. Показатели эффективности лечения
холецистохоледохолитиаза, М ± m
Table 3. Values of
efficiency of treatment of cholecystocholedocholithiasis, М ± m
|
Values |
Single-step management |
Two-step management |
||||||
|
Laparoscopic cholecystectomy, |
Minilaparotomy cholecytectomy, |
Standard cholecytectomy, |
Total, |
Laparoscopic cholecystectomy, |
Minilaparotomy cholecytectomy, |
Standard cholecytectomy, |
Total, |
|
|
Bed-days in ICU |
0.5 ± 0.4 |
0.8 ± 0.7 |
1.5 ± 0.7 |
1.0 ± 0.5 |
0.6 ± 0.5 |
1.2 ± 0.7 |
2.2 ± 1.1 |
1.5 ± 0.8**** |
|
Bed-days in hospital |
6.8 ± 1.6 |
7.3 ± 2.5 |
12.6 ± 1.7 |
9.1 ± 2.1 |
13.2 ± 1.3* |
13.8 ± 2.1** |
18.8 ± 1.8*** |
15.1 ± 1.7**** |
Note: * – difference between values for one- and two-step management (p < 0.05); ** – difference between values for one- and two-step management (p < 0.05); *** – difference between values for one- and two-step management (p < 0.05); **** – difference between values for one- and two-step management (p < 0.05).
CONCLUSION
The intrasurgical antegrade endoscopic papillosphincterotomy with one-stage management of cholecystocholedocholithiasis showed its efficiency as compared to two-stage management with retrograde endoscopic papillosphincterotomy in emergency patients. One-stage surgical treatment of complicated cholelithiasis showed the decrease in ICU, surgery unit and hospital stay. Intrasurgical antegrade endoscopic papillosphincterotomy decreased the rate of complications relating to transpapillary interventions (1.1 %) in contrast to retrograde ones (3 %). Intrasurgical antegrade endoscopic papillosphincterotomy with one-stage management of cholecystocholedocholithiasis promoted the correction of almost 1/3 of urgent patients without retrograde interventions for MDP, resulting in the decrease in possible complications.
Information on financing and conflicts of interests
The study was conducted without sponsorship. The authors declare the absence of any clear or potential conflicts of interests relating to publication of this article.
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