Soto FC, Higa SG, Brasesco OE, Mehran A, Szomstein S, Zundel N, Rosenthal RJ

Language: Spanish
References: 42
Page: 144-148
PDF size: 54.23 Kb.

ABSTRACT

Until the 19th century, nature’s cure for choledocholithiasis was spontaneous stone passage or internal fistula formation, which would result in cure or death. In 1882, Langenbuch performed the first cholecystectomy. In 1890, Courvoisier performed the first direct surgery on the common bile duct. It was nearly a century later before laparoscopy was introduced as a surgical approach to cholecystectomy, which started the evolution of minimally invasive surgery. Diagnosing and treating common bile duct stones has been a challenge for surgeons, radiologists, and gastroenterologists ever since the first gallbladder removal in 1882. At that time, the technique was to search the common bile duct for stones and push the found stones into the duodenum. Initially, common bile duct explorations were negative about 50% of the time, and retained stones could be found in 25% of patients who underwent CBDE. The introduction of intraoperative cholangiography (IOC) in 1931 by Pablo Mirizzi drastically reduced the rate of negative common bile duct explorations to 6% of all cases and retained choledocholithiasis to 11% of all cases. The incidence of retained stones declined to 3% after Mc Iver introduced rigid choledochoscopy in 1970. In 1974, endoscopic retrograde sphincterotomy was introduced as a non-surgical option for common bile duct stones. The advent of the endoscopic era of gallstone management permanently changed the treatment and significance of retained calculi. Case series of large numbers of patients treated with endoscopic retrograde sphincterotomy reported success rates of 90% to 95% with a morbidity rate of 15% and mortality rate of 1%. However, reports of preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by open cholecystectomy failed to show a significant reduction in morbidity and mortality compared to open cholecystectomy with or without common bile duct exploration. Subsequently, ERCP for suspected choledocholithiasis was not commonly used as a preoperative procedure in patients with suspected choledocholithiasis until 1989, when laparoscopic cholecystectomy was introduced. The introduction of laparoscopic cholecystectomy did not change the basic rationale for the treatment of cholelithiasis, but it did for common bile duct calculi. Before laparoscopic cholecystectomy, patients underwent intraoperative cholangiography during open cholecystectomy if common bile duct stones were suspected. Patients with signs of common bile duct stones underwent common bile duct exploration. After laparoscopic cholecystectomy was introduced, preoperative ERCP in many institutions became the standard approach for patients with suspected common bile duct stones. Laparoscopic cholecystectomy would then be performed after the duct was shown to be free of stones. When common bile duct stones were encountered during the laparoscopic procedure, some patients would be relegated to postoperative ERCP and endoscopic retrograde sphincterotomy. The main reasons for this “surgical behavior” were the lack of satisfactory techniques for laparoscopic intraoperative cholangiography and common bile duct exploration and the surgeon’s desire to avoid converting the operation to an open procedure. During the decade following the introduction of therapeutic laparoscopy for the biliary tree, several laparoscopic techniques for common bile duct exploration were developed. With these techniques, patients with common bile duct stones can be treated in an operative session, which avoids the potential complication of subsequent procedures, such as ERCP. The results of these techniques are variable, but in selected and experienced hands, they are superior to those reported with ERCP and endoscopic retrograde sphincterotomy. Some authors have reported results that compare favorably with those achieved with open common bile duct exploration. Despite the fact that laparoscopic common bile duct exploration has reached high levels of success, surgeon expertise and availability varies greatly. This variability in success has created a difference in opinion about the best approach for the patients with suspected common bile duct stones.

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