The Role of Laparoscopic Intraoperative Ultrasonography in Patients with Suspected Choledocholithiasis. Summary of the Doctoral Thesis

Abstract

One of the most common conditions in Europe that requires surgical intervention is cholelithiasis or gallstone disease. The prevalence of gallstone disease in Latvia and European countries is high. Increase of gallstone disease is associated with specific demographic pattern due to the large proportion of old people especially female gender and is associated with Western diet and life style. According to the statistics, about 5.9–21.9 % of the European population may suffer from cholelithiasis (Aerts and Penninckx, 2003), and 11–21 % of patients who undergo cholecystectomy may have stones in the common bile duct (CBD) (Costi et al., 2014). Choledocholithiasis is one of the most common complications of gallstone disease and may couse biliary obstruction. Usually it manifests with biliary pancreatitis and ascending biliary infection frequently accopanied by mechanical jaundice and clinical presentation of cholangitis. In all of these clinical conditions risk of development of sepsis and multiorgan disfunction is increased. So, frequently it requires treatment in the intensive care unit and expensive as well as time-consuming diagnostic and therapeutic methods. This category of patients requires multidisciplinary approach involving radiology, endoscopy, gastroenterology and intensive care specialists who collaborate with surgeons. Overall treatment costs are significant, hospital stay is prolonged and associated with high mortality. Radiological imaging of choledocholithiasis by magnetic resonance cholangiopancreatography (MRCP) is a golden standard for patients with gallstone disease in preoperative setting, however, some studies have reported unconformity between preoperative MRCP and intraoperative finding up to 15–20 %, as well as MRCP may miss stones less then 5 mm especially in patients with biliary pancreatitis (Costi et al., 2014). Moreover, application of MRCP in urgently admitted patients has its limits. According to the abovementioned facts the requirement for new solutions in more precise detection of choledocholithiasis is crucial. Despite the wide spectrum of the different diagnostic and treatment modalities, the question remains, how cheaper and more accurately confirm bile duct stones and what is the most effective treatment method? Over the last 30 years, many diagnostic modalities, endoscopy and laparoscopy has changed, so the management of the choledocholithiasis has become different. During the laparoscopic cholecystectomy intraoperative control of CBD stones is not performed routinely. It is not recommended in patients who are in low risk of choledocholithiasis and in patients after preoperative endoscopic papillotomy and clearance of the CBD (Costi et al., 2014). Intraoperative control of the choledocholithiasis is also deemed to be unnecessary in patients with MRCP proved absence of biliary stones before surgery. Endoscopic retrograde cholangio-pancreatography (ERCP) typically combined with sphincterotomy, is a routine therapeutic procedure in the cases of proven stones in the CBD. However, it is associated with up to a 9.8 % complication rate, including post-ERCP pancreatitis, bleeding and duodenal perforation (Freeman at al., 1996) as well as restrictions in patients with biliary pancreatitis (Laura and Eldon, 2012; Anu and Kapoor, 2012; Sgouros and Bergele, 2006). Technical skills and proper clinical indications for the procedure is a major determinant of its success, rather than the age or the general medical condition of the patients (Laura and Eldon, 2012). Laparoscopic option of treatment of emergent patients with a complicated gallstone disease and suspected choledocholithiasis is more challenging due to the limited time for preoperative MRCP or ERCP. Surgical intervention is often more complicated due to oedema and inflammation. Most common intraoperative diagnostic methods of choledocholithiasis are intraoperative cholangiography (IOC) and intraoperative ultrasound (IOUS). Although IOC may improve the diagnostic accuracy, it is associated with a 5.1 % unsuccessful procedure rate, increased operative time and a 15–20 % rate of overlooked biliary stones (Bencini et al., 2014; Costi et al., 2014; Tazuma, 2006). Development of the laparoscopic IOUS was an essential and reasonable alternative to IOH and mostly to preoperative specific imaging. It provides not only information about the content of the bile duct, but also helps to navigate in caes of ambiguous anatomy. In addition, IOUS can be repeated at any stage of operation. In Latvia IOUS regarded as a relatively new diagnostic modality for detection of common bile duct stones and previously have not been studied.