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Single-step treatment of gallbladder and bile duct stones: A combined endoscopic-laparoscopic technique
Single-step treatment of gallbladder and bile duct stones: a combined endoscopic-laparoscopic technique Giuseppe Iodice, MD, Cristiano Giardiello, MD, Giampiero Francica, MD, Gennaro Sarrantonio, MD, Giovanni Angelone, MD, Stefano Cristiano, MD, Raffaele Finelli, MD, Giampaolo Tramontano, MD Casoria, Italy
Background: The introduction of laparoscopic cholecystectomy has given rise to a debate as to whether endoscopic retrograde cholangiopancreatography (ERCP) should be performed before or after cholecystectomy in patients with bile duct stones. Methods: This study evaluated the efficacy of treatment of cholecystocholedocholithiasis in a single step by performing ERCP during surgery in 52 patients (35 women, 17 men; mean age 57.0 years; age range 20 to 89 years). Laparoscopic intraoperative cholangiography via the cystic duct was carried out to confirm the presence of duct stones. A soft-tipped guidewire was passed through the cystic duct and papilla into the duodenum. A papillotome was inserted endoscopically over the guidewire. Endoscopic sphincterectomy was performed and the stones removed with balloon and basket catheters. Results: Endoscopic stone removal was successful in 94% of cases without complications related to ERCP or surgery. Although operative time was lengthened by about 20 minutes, the hospital stay was as short and equal to that for simple laparoscopic cholecystectomy (3 days on average). Conclusions: The single-step combined endoscopic-laparoscopic technique is safe and effective for treatment of patients with gallbladder and bile duct stones. (Gastrointest Endosc 2001;53:336-8.)
Laparoscopic cholecystectomy (LC) is the treatment of choice for patients with symptoms due to cholelithiasis1,2 and has also modified the therapeutic strategy for choledocholithiasis.3-8 To preserve the minimally invasive nature of the laparoscopic procedure a number of approaches have been described.5-12 Two approaches are available: (1) two-step management, i.e., ERCP with endoscopic sphincterotomy (ES) before or after surgery, and (2) a one-step approach, i.e., laparoscopic bile duct exploration (LBDE).2,12,13 Theoretically the most desirable, LBDE is still a highly demanding technique and is not widely used except in a few centers.1,2,12,14 The major drawback of preoperative ERCP is the high number (50% to 60%) of negative examinations even when strict selective criteria are used,7,8,15,16 whereas postoperative ERCP entails the risk of a second operative intervention if the procedure is unsuccessful.14,17 In this study the feasibility and effectiveness of Received March 21, 2000. For revision June 22, 2000. Accepted October 12, 2000. From the Unità Operativa di Gastroenterologia ed Endoscopia Digestiva, Unità Operativa di Ecografia Diagnostica ed Ecointerventiva, and Unità Operativa di Chirurgia Miniinvasiva, Presidio Sanitario S.M. della Pietà, Casoria, Italy. Presented as a poster at Digestive Disease Week, May 1999, Orlando, Florida. Reprint requests: G. Iodice, MD, Via Giovanni Amato 20, 80026 Casoria (NA), Italy. Copyright © 2001 by the American Society for Gastrointestinal Endoscopy 0016-5107/2001/$35.00 + 0 37/1/112193 doi:10.1067/mge.2001.112193 VOLUME 53, NO. 3, 2001
single-step combined endoscopic-laparoscopic treatment of gallbladder and BD stones was assessed. PATIENTS AND METHODS Between July 1996 and January 2000, 812 LCs were performed, and 52 patients (mean age 57.0 years; age range 20 to 89 years; 35 women and 17 men) with gallbladder and BD stones underwent the combined endoscopic-laparoscopic technique. Twelve patients (group I) had abnormal liver enzymes and a normal BD by US. In this group 7 patients had a recent or remote episode of acute biliary pancreatitis and/or jaundice. Twenty-five patients (group II) had elevated liver enzymes and a dilated (greater than 7 mm) BD at US, and in 8 of these patients choledocholithiasis had also been demonstrated at US. In this group 8 patients had a recent or remote episode of acute biliary pancreatitis and/or jaundice. In 7 patients (group III) liver enzymes were normal but the BD was dilated at US but stones were demonstrated in only 1 case; in this group 1 patient had had a recent episode of acute biliary pancreatitis. Eight patients (group IV) had normal liver enzymes and US, 4 of whom had had a recent or remote episode of acute biliary pancreatitis and/or jaundice. In the other 4 patients the cystic duct appeared dilated at laparoscopy. Selection criteria changed over time. Early in our experience, patients with either clinically suspected BD stones, later confirmed at intraoperative cholangiography (IOC) (groups I, II, II), or with stones discovered incidentally at IOC (group IV) underwent the one-step treatment. During the last year, patients with preoperatively proven BD stones (group II with US demonstration of choledocholithiasis) without complications or suspected neoplasm underwent the combined technique. GASTROINTESTINAL ENDOSCOPY
336
Endoscopic-laparoscopic technique for gallbladder and bile duct stones
The study was approved by the ethical committee of our institution and informed written consent was obtained from all patients. All patients were positioned supine on the operating table. After the creation of pneumoperitoneum, IOC was performed by using a 5F catheter kept in place with one or more clips on the cystic duct. When BD stones were demonstrated, the endoscopic procedure was begun after partial deflation of pneumoperitoneum. A videoduodenoscope (ED 3440T, Pentax GMBH, Hamburg, Germany) was used with the video processor and monitor placed behind the anesthesia drapes at the patient’s head. Duodenoscope manipulation through the stomach and maneuvers to reach the papilla were identical to those for ERCP with the patient prone. The major differences from standard ERCP were (1) the endoscopist worked with his back toward the patient from the left side of the operating table and (2) rapid cannulation of the papilla because a softtipped guidewire (480 cm, 0.035 inch, Tracer; Wilson-Cook Medical Inc., Cook Ireland limited, Limerick, Ireland) had been passed through the cystic duct and papilla into the duodenum by the surgeon before removal of the gallbladder. The guidewire, grasped with a snare, was pulled through the accessory channel of the duodenoscope. Then the papillotome (CCPT-25; Wilson-Cook Medical Inc.) was inserted endoscopically over the guidewire. ES was performed and the stones removed with balloon and/or basket catheters. For giant and/or impacted stones mechanical lithotripsy was performed. Cholecystectomy was then performed. A Student t test for continuous variables was used for statistical analysis.
RESULTS The ES and stone removal were carried out successfully in all but 3 patients (94%). In an 89-yearold man with a peripapillary diverticulum, an endoprothesis was positioned and left in place. In the other 2 patients, giant, impacted stones were removed either at a subsequent ERCP or by laparoscopic choledochotomy. In 4 other patients the presence of a peripapillary diverticulum did not hamper the endoscopic procedure. In 9 patients (17%) stones were smaller than 5 mm. The mean time duration of the endoscopic procedure was 23 minutes (range 12 to 50 minutes); the mean time for the combined technique was 85.6 minutes (range 60 to 180 minutes) as compared with 40.6 minutes (range 25 to 120 minutes) for simple LC (p < 0.0001). The mean hospital stay was 3.1 days (range 3 to 7 days) for patients treated with the combined approach as compared with 3.0 days (range 3 to 5 days) for patients who underwent LC alone (p = 0.1). Complications related to either ERCP or LC did not occur and in no case was conversion to open cholecystectomy required. VOLUME 53, NO. 3, 2001
G Iodice, C Giardiello, G Francica, et al.
DISCUSSION The timing of ERCP (whether before or after surgery) for removal of BD stones in patients with symptoms due to cholecystolithiasis is a vigorously debated issue, especially since the introduction of LC.3,4,8,9,11 Three therapeutic strategies are in general available and the final choice depends on expertise and experience. These include (1) endoscopic BD stone removal before or after surgical intervention, (2) LBDE, and (3) open BD exploration. According to the findings of a consensus development conference held by the European Association for Endoscopic Surgery (E.A.E.S.) the first 2 treatment modalities are preferable.10,13 LBDE offers the advantage of a one-step approach but is technically more demanding and more expensive and is routinely carried out only in a few specialized institutions.1,2,12,14 LBDE is also time-consuming with a duration that is twice that of our combined endoscopic-laparoscopic approach. A randomized trial18 has demonstrated that laparoscopic clearance of ductal stones (by the transcystic route or by supraduodenal BD exploration) was equally effective in removing stones compared to the two-step approach (i.e., preoperative ERCP and subsequent LC) but was superior in terms of lower morbidity and shorter hospital stay. However, two points should be stressed: (1) the great majority of patients in that study were treated by the transcystic route with a success rate of 80% and (2) when duct stones were multiple, large, or located within the proximal BDs, supraduodenal access was mandatory and resulted in higher morbidity and conversion rate to the open procedure as well as a longer hospital stay with a success rate of 85%. As far as the two-stage approach, preoperative ERCP with ES entails a high number of negative examinations,7,9,15,16 approximately 50% to 60%, and may lengthen hospital stay because of possible complications (particularly pancreatitis.)3,8 Postcholecystectomy endoscopic treatment of BD stones has a low (2% to 4%) but definite failure rate, which leads to further endoscopic procedures or relaparotomy.12,14,17 The limitations of two-stage management of BD stones was addressed by combining laparoscopy and endoscopy in the operating room. This laparoendoscopic “rendezvous” is previously described11,13,16 but has not gained favor owing to the technical difficulty of performing ERCP at the operating table.7 In our opinion the crucial technical point of our technique is the insertion of a guidewire through the cystic duct. This preliminary step allowed cannulation, which, in turn, accounted for (1) a high success rate in clearing ductal stones (94%), similar to that reported by Cavina et al.14 (93.7%), even in difficult GASTROINTESTINAL ENDOSCOPY
337
G Iodice, C Giardiello, G Francica, et al.
Endoscopic-laparoscopic technique for gallbladder and bile duct stones
cases such as giant/impacted calculi or the presence of large peripapillary diverticula; (2) a lack of complications (especially pancreatitis) as reported by others12,14,17; (3) a mean time of hospital stay that was similar to that of simple LC, although the operating room time of the combined technique was longer than that of simple LC. Because LBDE is rarely performed at our institution, our patients were all candidates for preoperative or postoperative ERCP during the same hospital stay; thus the one-stage approach was highly cost-effective. Early in our experience only a few patients were selected with suspected ductal stones or stones found incidentally by IOC; the favorable results changed our approach to include all patients with a proved or suspected preoperative diagnosis of cholecystocholedocholithiasis. Currently preoperative ERCP is being reserved for patients requiring urgent BD decompression and/or those in whom a neoplasm is suspected. Postoperative ERCP is performed only in the few cases in which the intraoperative endoscopic procedure is unsuccessful. In conclusion, the combined endoscopic-laparoscopic technique is safe and effective for treatment of gallbladder and BD stones in a single step.
10.
REFERENCES
15.
1. Strasberg SM, Callery MP, Soper NJ. Laparoscopic surgery of the bile ducts. Gastrointest Endosc Clin N Am 1996;6:81-105. 2. Strasberg SM. Laparoscopic biliary surgery. Gastroenterol Clin North Am 1999;28:117-32. 3. Rieger R, Wayand W. Yield of prospective non-invasive evaluation of the common bile duct combined with selective ERCP/sphincterotomy in 1390 consecutive laparoscopic cholecystectomy patients. Gastrointest Endosc 1995;42:6-12. 4. Santucci L, Natalini G, Sarpi L, Fiorucci S, Solinas A, Morelli A. Selective endoscopic retrograde cholangiography and preoperative, bile duct stone removal in patients scheduled for laparoscopic cholecystectomy: a prospective study. Am J Gastroenterol 1996;91:1326-30. 5. Berci G, Morgenstern L. Laparoscopic management of com-
338
GASTROINTESTINAL ENDOSCOPY
6. 7.
8.
9.
11.
12.
13. 14.
16.
17. 18.
mon bile duct stones: a multi institutional SAGES study. Surg Endosc 1994;8:1168-75. Kozarek RA. Laparoscopic cholecystectomy: what to do with the common duct. Gastrointest Endosc 1993;39:99-100. Aliperti G, Edmundowicz SA, Soper NJ, Ashley SW. Combined endoscopic sphincterotomy and laparoscopic cholecystectomy in patients with choledocholithiasis and cholecystolithiasis. Ann Intern Med 1991;115:783-5. Soetikno RM, Montes H, Carr-Locke DL. Endoscopic management of choledocholithiasis. J Clin Gastroenterol 1998;27: 296-305. Vanneman W, Kingsbury R, Buberman E, Lee M. When is ERCP indicated before laparoscopic cholecystectomy? [abstract]. Gastrointest Endosc 1992;38:265. Rosenthal RJ, Rossi RL, Martin RF. Options and strategies for the management of choledocholithiasis. World J Surg 1998;22:1125-32. Tham TCK, Lichtenstein DR, Vandervoort J, Wong RCK, Brooks BScD, Van Dam J, et al. Role of endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis in patients undergoing laparoscopic cholecystectomy. Gastrointest Endosc 1998;47:50-6. Huntington TR, Bohlman TW. Laparoscopic biliary guide wire: a simplified approach to choledocholithiasis. Gastrointest Endosc 1997;45:295-7. Committee E.A.E.S. Diagnosis and treatment of common bile duct stones (CBDS). Surg Endosc 1998;12:856-64. Cavina E, Franceschi M, Sidoti F, Goletti O, Buccianti P, Chiarugi M. Laparo-endoscopic “rendezvous”: a new technique in the choledocholithiasis treatment. Hepatogastroenterology 1998;45:1430-5. Davis WZ, Cotton PB, Arias RS, Williams DM, Onken JE. ERCP and sphincterotomy in the context of laparoscopic cholecystectomy: academic and community practice patterns and results. Am J Gastroenterol 1997;92:597-601. Onken JE, Brazer SR, Eisen GM, Williams DM, Bouras EP, DeLong ER, et al. Predicting the presence of choledocholithiasis in patients with symptomatic cholelithiasis. Am J Gastroenterol 1996;91:762-7. Forlano R. La sfinterotomia endoscopica intraoperatoria (SEI). Giorn Ital End Dig 1997;20:95-7. Cuschieri A, Lezoche E, Morino M, Croce E, Lacy A, Toouli J, et al. E.A.E.S. multicenter prospective randomized trial comparing two-stage vs single-stage management of patients with gallstone disease and ductal calculi. Surg Endosc 1999;13:952-7.
VOLUME 53, NO. 3, 2001
Background: The introduction of laparoscopic cholecystectomy has given rise to a debate as to whether endoscopic retrograde cholangiopancreatography (ERCP) should be performed before or after cholecystectomy in patients with bile duct stones. Methods: This study evaluated the efficacy of treatment of cholecystocholedocholithiasis in a single step by performing ERCP during surgery in 52 patients (35 women, 17 men; mean age 57.0 years; age range 20 to 89 years). Laparoscopic intraoperative cholangiography via the cystic duct was carried out to confirm the presence of duct stones. A soft-tipped guidewire was passed through the cystic duct and papilla into the duodenum. A papillotome was inserted endoscopically over the guidewire. Endoscopic sphincterectomy was performed and the stones removed with balloon and basket catheters. Results: Endoscopic stone removal was successful in 94% of cases without complications related to ERCP or surgery. Although operative time was lengthened by about 20 minutes, the hospital stay was as short and equal to that for simple laparoscopic cholecystectomy (3 days on average). Conclusions: The single-step combined endoscopic-laparoscopic technique is safe and effective for treatment of patients with gallbladder and bile duct stones. (Gastrointest Endosc 2001;53:336-8.)
Laparoscopic cholecystectomy (LC) is the treatment of choice for patients with symptoms due to cholelithiasis1,2 and has also modified the therapeutic strategy for choledocholithiasis.3-8 To preserve the minimally invasive nature of the laparoscopic procedure a number of approaches have been described.5-12 Two approaches are available: (1) two-step management, i.e., ERCP with endoscopic sphincterotomy (ES) before or after surgery, and (2) a one-step approach, i.e., laparoscopic bile duct exploration (LBDE).2,12,13 Theoretically the most desirable, LBDE is still a highly demanding technique and is not widely used except in a few centers.1,2,12,14 The major drawback of preoperative ERCP is the high number (50% to 60%) of negative examinations even when strict selective criteria are used,7,8,15,16 whereas postoperative ERCP entails the risk of a second operative intervention if the procedure is unsuccessful.14,17 In this study the feasibility and effectiveness of Received March 21, 2000. For revision June 22, 2000. Accepted October 12, 2000. From the Unità Operativa di Gastroenterologia ed Endoscopia Digestiva, Unità Operativa di Ecografia Diagnostica ed Ecointerventiva, and Unità Operativa di Chirurgia Miniinvasiva, Presidio Sanitario S.M. della Pietà, Casoria, Italy. Presented as a poster at Digestive Disease Week, May 1999, Orlando, Florida. Reprint requests: G. Iodice, MD, Via Giovanni Amato 20, 80026 Casoria (NA), Italy. Copyright © 2001 by the American Society for Gastrointestinal Endoscopy 0016-5107/2001/$35.00 + 0 37/1/112193 doi:10.1067/mge.2001.112193 VOLUME 53, NO. 3, 2001
single-step combined endoscopic-laparoscopic treatment of gallbladder and BD stones was assessed. PATIENTS AND METHODS Between July 1996 and January 2000, 812 LCs were performed, and 52 patients (mean age 57.0 years; age range 20 to 89 years; 35 women and 17 men) with gallbladder and BD stones underwent the combined endoscopic-laparoscopic technique. Twelve patients (group I) had abnormal liver enzymes and a normal BD by US. In this group 7 patients had a recent or remote episode of acute biliary pancreatitis and/or jaundice. Twenty-five patients (group II) had elevated liver enzymes and a dilated (greater than 7 mm) BD at US, and in 8 of these patients choledocholithiasis had also been demonstrated at US. In this group 8 patients had a recent or remote episode of acute biliary pancreatitis and/or jaundice. In 7 patients (group III) liver enzymes were normal but the BD was dilated at US but stones were demonstrated in only 1 case; in this group 1 patient had had a recent episode of acute biliary pancreatitis. Eight patients (group IV) had normal liver enzymes and US, 4 of whom had had a recent or remote episode of acute biliary pancreatitis and/or jaundice. In the other 4 patients the cystic duct appeared dilated at laparoscopy. Selection criteria changed over time. Early in our experience, patients with either clinically suspected BD stones, later confirmed at intraoperative cholangiography (IOC) (groups I, II, II), or with stones discovered incidentally at IOC (group IV) underwent the one-step treatment. During the last year, patients with preoperatively proven BD stones (group II with US demonstration of choledocholithiasis) without complications or suspected neoplasm underwent the combined technique. GASTROINTESTINAL ENDOSCOPY
336
Endoscopic-laparoscopic technique for gallbladder and bile duct stones
The study was approved by the ethical committee of our institution and informed written consent was obtained from all patients. All patients were positioned supine on the operating table. After the creation of pneumoperitoneum, IOC was performed by using a 5F catheter kept in place with one or more clips on the cystic duct. When BD stones were demonstrated, the endoscopic procedure was begun after partial deflation of pneumoperitoneum. A videoduodenoscope (ED 3440T, Pentax GMBH, Hamburg, Germany) was used with the video processor and monitor placed behind the anesthesia drapes at the patient’s head. Duodenoscope manipulation through the stomach and maneuvers to reach the papilla were identical to those for ERCP with the patient prone. The major differences from standard ERCP were (1) the endoscopist worked with his back toward the patient from the left side of the operating table and (2) rapid cannulation of the papilla because a softtipped guidewire (480 cm, 0.035 inch, Tracer; Wilson-Cook Medical Inc., Cook Ireland limited, Limerick, Ireland) had been passed through the cystic duct and papilla into the duodenum by the surgeon before removal of the gallbladder. The guidewire, grasped with a snare, was pulled through the accessory channel of the duodenoscope. Then the papillotome (CCPT-25; Wilson-Cook Medical Inc.) was inserted endoscopically over the guidewire. ES was performed and the stones removed with balloon and/or basket catheters. For giant and/or impacted stones mechanical lithotripsy was performed. Cholecystectomy was then performed. A Student t test for continuous variables was used for statistical analysis.
RESULTS The ES and stone removal were carried out successfully in all but 3 patients (94%). In an 89-yearold man with a peripapillary diverticulum, an endoprothesis was positioned and left in place. In the other 2 patients, giant, impacted stones were removed either at a subsequent ERCP or by laparoscopic choledochotomy. In 4 other patients the presence of a peripapillary diverticulum did not hamper the endoscopic procedure. In 9 patients (17%) stones were smaller than 5 mm. The mean time duration of the endoscopic procedure was 23 minutes (range 12 to 50 minutes); the mean time for the combined technique was 85.6 minutes (range 60 to 180 minutes) as compared with 40.6 minutes (range 25 to 120 minutes) for simple LC (p < 0.0001). The mean hospital stay was 3.1 days (range 3 to 7 days) for patients treated with the combined approach as compared with 3.0 days (range 3 to 5 days) for patients who underwent LC alone (p = 0.1). Complications related to either ERCP or LC did not occur and in no case was conversion to open cholecystectomy required. VOLUME 53, NO. 3, 2001
G Iodice, C Giardiello, G Francica, et al.
DISCUSSION The timing of ERCP (whether before or after surgery) for removal of BD stones in patients with symptoms due to cholecystolithiasis is a vigorously debated issue, especially since the introduction of LC.3,4,8,9,11 Three therapeutic strategies are in general available and the final choice depends on expertise and experience. These include (1) endoscopic BD stone removal before or after surgical intervention, (2) LBDE, and (3) open BD exploration. According to the findings of a consensus development conference held by the European Association for Endoscopic Surgery (E.A.E.S.) the first 2 treatment modalities are preferable.10,13 LBDE offers the advantage of a one-step approach but is technically more demanding and more expensive and is routinely carried out only in a few specialized institutions.1,2,12,14 LBDE is also time-consuming with a duration that is twice that of our combined endoscopic-laparoscopic approach. A randomized trial18 has demonstrated that laparoscopic clearance of ductal stones (by the transcystic route or by supraduodenal BD exploration) was equally effective in removing stones compared to the two-step approach (i.e., preoperative ERCP and subsequent LC) but was superior in terms of lower morbidity and shorter hospital stay. However, two points should be stressed: (1) the great majority of patients in that study were treated by the transcystic route with a success rate of 80% and (2) when duct stones were multiple, large, or located within the proximal BDs, supraduodenal access was mandatory and resulted in higher morbidity and conversion rate to the open procedure as well as a longer hospital stay with a success rate of 85%. As far as the two-stage approach, preoperative ERCP with ES entails a high number of negative examinations,7,9,15,16 approximately 50% to 60%, and may lengthen hospital stay because of possible complications (particularly pancreatitis.)3,8 Postcholecystectomy endoscopic treatment of BD stones has a low (2% to 4%) but definite failure rate, which leads to further endoscopic procedures or relaparotomy.12,14,17 The limitations of two-stage management of BD stones was addressed by combining laparoscopy and endoscopy in the operating room. This laparoendoscopic “rendezvous” is previously described11,13,16 but has not gained favor owing to the technical difficulty of performing ERCP at the operating table.7 In our opinion the crucial technical point of our technique is the insertion of a guidewire through the cystic duct. This preliminary step allowed cannulation, which, in turn, accounted for (1) a high success rate in clearing ductal stones (94%), similar to that reported by Cavina et al.14 (93.7%), even in difficult GASTROINTESTINAL ENDOSCOPY
337
G Iodice, C Giardiello, G Francica, et al.
Endoscopic-laparoscopic technique for gallbladder and bile duct stones
cases such as giant/impacted calculi or the presence of large peripapillary diverticula; (2) a lack of complications (especially pancreatitis) as reported by others12,14,17; (3) a mean time of hospital stay that was similar to that of simple LC, although the operating room time of the combined technique was longer than that of simple LC. Because LBDE is rarely performed at our institution, our patients were all candidates for preoperative or postoperative ERCP during the same hospital stay; thus the one-stage approach was highly cost-effective. Early in our experience only a few patients were selected with suspected ductal stones or stones found incidentally by IOC; the favorable results changed our approach to include all patients with a proved or suspected preoperative diagnosis of cholecystocholedocholithiasis. Currently preoperative ERCP is being reserved for patients requiring urgent BD decompression and/or those in whom a neoplasm is suspected. Postoperative ERCP is performed only in the few cases in which the intraoperative endoscopic procedure is unsuccessful. In conclusion, the combined endoscopic-laparoscopic technique is safe and effective for treatment of gallbladder and BD stones in a single step.
10.
REFERENCES
15.
1. Strasberg SM, Callery MP, Soper NJ. Laparoscopic surgery of the bile ducts. Gastrointest Endosc Clin N Am 1996;6:81-105. 2. Strasberg SM. Laparoscopic biliary surgery. Gastroenterol Clin North Am 1999;28:117-32. 3. Rieger R, Wayand W. Yield of prospective non-invasive evaluation of the common bile duct combined with selective ERCP/sphincterotomy in 1390 consecutive laparoscopic cholecystectomy patients. Gastrointest Endosc 1995;42:6-12. 4. Santucci L, Natalini G, Sarpi L, Fiorucci S, Solinas A, Morelli A. Selective endoscopic retrograde cholangiography and preoperative, bile duct stone removal in patients scheduled for laparoscopic cholecystectomy: a prospective study. Am J Gastroenterol 1996;91:1326-30. 5. Berci G, Morgenstern L. Laparoscopic management of com-
338
GASTROINTESTINAL ENDOSCOPY
6. 7.
8.
9.
11.
12.
13. 14.
16.
17. 18.
mon bile duct stones: a multi institutional SAGES study. Surg Endosc 1994;8:1168-75. Kozarek RA. Laparoscopic cholecystectomy: what to do with the common duct. Gastrointest Endosc 1993;39:99-100. Aliperti G, Edmundowicz SA, Soper NJ, Ashley SW. Combined endoscopic sphincterotomy and laparoscopic cholecystectomy in patients with choledocholithiasis and cholecystolithiasis. Ann Intern Med 1991;115:783-5. Soetikno RM, Montes H, Carr-Locke DL. Endoscopic management of choledocholithiasis. J Clin Gastroenterol 1998;27: 296-305. Vanneman W, Kingsbury R, Buberman E, Lee M. When is ERCP indicated before laparoscopic cholecystectomy? [abstract]. Gastrointest Endosc 1992;38:265. Rosenthal RJ, Rossi RL, Martin RF. Options and strategies for the management of choledocholithiasis. World J Surg 1998;22:1125-32. Tham TCK, Lichtenstein DR, Vandervoort J, Wong RCK, Brooks BScD, Van Dam J, et al. Role of endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis in patients undergoing laparoscopic cholecystectomy. Gastrointest Endosc 1998;47:50-6. Huntington TR, Bohlman TW. Laparoscopic biliary guide wire: a simplified approach to choledocholithiasis. Gastrointest Endosc 1997;45:295-7. Committee E.A.E.S. Diagnosis and treatment of common bile duct stones (CBDS). Surg Endosc 1998;12:856-64. Cavina E, Franceschi M, Sidoti F, Goletti O, Buccianti P, Chiarugi M. Laparo-endoscopic “rendezvous”: a new technique in the choledocholithiasis treatment. Hepatogastroenterology 1998;45:1430-5. Davis WZ, Cotton PB, Arias RS, Williams DM, Onken JE. ERCP and sphincterotomy in the context of laparoscopic cholecystectomy: academic and community practice patterns and results. Am J Gastroenterol 1997;92:597-601. Onken JE, Brazer SR, Eisen GM, Williams DM, Bouras EP, DeLong ER, et al. Predicting the presence of choledocholithiasis in patients with symptomatic cholelithiasis. Am J Gastroenterol 1996;91:762-7. Forlano R. La sfinterotomia endoscopica intraoperatoria (SEI). Giorn Ital End Dig 1997;20:95-7. Cuschieri A, Lezoche E, Morino M, Croce E, Lacy A, Toouli J, et al. E.A.E.S. multicenter prospective randomized trial comparing two-stage vs single-stage management of patients with gallstone disease and ductal calculi. Surg Endosc 1999;13:952-7.
VOLUME 53, NO. 3, 2001