Abstract

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BACKGROUND: This prospective study was done to assess the possibility of performing laparoscopic ultrasound during cholecystectomy and the accuracy as a diagnostic tool for the stone in the common bile duct
MATERIALS AND METHODS: Seventy patient with gall stones were included in the study , patient with dilated bile duct with or without visible CBD stone were excluded? .
RESULTS: The procedure was completed safely with 63 patient , in 48 patient the CBD was seen clearly and stone was delineated in three patient only.
CONCLUSIONS: In our experience Intraoperative ultrasound could not give us a secure diagnosis of the CBD stone. This might be attributed to the learning curve, but despite of that there was the advantage of suspicious cases that were followed by ERCP .

Introduction

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Intra-operative cholangiography is the gold standard for the CBD stone diagnosis during surgery , but the procedure is taking a long time to perform and most of the surgeon were advocating it for certain cases . Intra-operative ultrasound is a promising, fast and non invasive with longer learning curve and a facility which might not be available
Intra-operative cIn recent Years it has been repeated attempts by Surgeons for the assessment of the Biliary system during Laparoscopic surgery to overcome the difficulties of laparoscopic cholecystectomy
Our aim was to assess if the routine use of intraoperative laparoscopic ultrasound during cholecystectomy is of any diagnostic help in detecting occult choledocholithiasis, Improve the dissection in acute cholecystitis and prevent bile duct injuries.

Methods

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This is a prospective study on 70 consecutive cases who were scheduled for laparoscopic cholecystectomy . The study was conducted from August 2006 to August 2008 . Laparoscopic Ultrasound (LUS) was performed on all patient except on patient where the common bile duct (CBD) is dilated , a high Liver enzymes, history of jaundice or pancreatitis and all patient who had preoperative Endoscopic Retrograde Cholangio- pancreatigography (ERCP).
Ultrasound is performed at the beginning of the surgery and if necessary it could be repeated at any stage of the course of the LC, the procedure is not completed in obesity and trocar site bleeding. Radiologist was present in the first few cases of the study .
Selection of patient : All patients with suspected stone in the CBD were sent for ERCP. Seventy patient were eligible to undergo laparoscopic intra-operative Ultrasound (LUS). The procedure was performed after insertion of 12mm trocar through the umbilicus and 10mm through the epigasric region. Aloka 7.5-MHz flexible linear laparoscopic transducer was used for for scanning(Figure 1). The ultrasound machine is adjacent to the LC tower .
Ultarsound Probe : ?The Length ?is 50 cm Scanning width is 38 mm and the diameter is 10 mm . The probe was used through 12mm trocar through the umbilical port? The Ultrasound Probe is inserted through the Umblical port through Diaphragmatic surface of the liver and the first area to be scanned is directly on the liver overlying the Gall bladder between segment V and IV without retracting the gall bladder. ( Figure 2)

DISCUSSION

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The standard preoperative workup for patients presenting with gall stones has reduced the need for IOC . Liver function tests, abdominal ultrasound, combined with clinical exam and history, constitute the entire workup for most patients. Any abnormality by the previous test may suggest the presence of choledocholithiasis. Unfortunately, these two methods for the CBD stone prediction is , are nonspecific and unreliable, (5) . MRCP and ERCP are also available methods for diagnosis a preoperative CBD stone (4,6,7) .
MRCP has the ability to accurately detect CBD stones and thus, noninvasively select those patients most likely to benefit from a preoperative procedures such as ERCP. Or exploration of the CBD (8). ERCP is not without complication such as bleeding perforation or acute pancreatitis . For this reason, the current use of ERCP as a routine screening tool for purely diagnostic purposes carries substantial risks. (9)
McFarlane et al , suggested categorizing the risk of CBD stone into groups to be able to identify those who are in real need for different type of intervention patients are classified preoperatively into high, and low risk groups. The high risk includes those patients with obvious clinical jaundice or cholangitis, choledocholithiasis or a dilated CBD on ultrasonography. Patients with a history of pancreatitis or jaundice, elevated preoperative bilirubin and alkaline phosphatase levels or multiple small gallstones carry a high risk of choledocholithiasis. Patients with large gallstones, without a history of jaundice or pancreatitis and with normal liver function tests are considered unlikely to have CBD stones and therefore at low risk . In our opinion these are the group that needs IOU .(3)
We implemented this principle with learning curve in applying IOU we could identify only two positive cases which makes it 3% .
Choledocholithiasis may occur in up to 3%-10% of all cholecystectomy patients of the mixed group , or as high as 14.7% in some series(2) . Laparoscopic ultrasound did not gain popularity because of the learning curve of performing it confidentially and the cost of the apparatus with the probe . compared to the Intra-operative cholangiography nevertheless it is considered faster than IOC , safe and non-invasive technique. (1) .
In recent years with the LC, intra-operative cholangiography (IOC) is not widely practiced , however high resolution ultrasound and pre-operative investigations ; assisted in identifying those who need further investigations such as Endoscopic Retrograde Cholangio Pancreaticography (ERCP) or Magnetic Retrograde Cholangio Pancreaticography (MRCP) prior to surgery .
These tests lowered the need for the routine IOC, however it is still applied for difficult LC and for assessing the anatomy and the anomaly of the biliary tree Our result showed that the LOS needs more training and interpretation . The diagnostic accuracy can not be assessed in the negative cases .
From a technical point of view, LUS is a more difficult procedure to perform and interpret the images accurately(1,2) . Very few surgeons are familiar with the equipment and needs technician to assist in manipulating the US . The results strongly depend on the operator's expertise. This is only achieved with experience whereas IOC can be performed and interpreted with very little training.
Conclusion : Despite the safety of the LUS the accuracy needs to re-assessed and with recent high resolution scanning the learning curve could be shortened with improvement of the sensitivity and Specificity prior to its generalization .

REFERENCES

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1. Perry K, Myers J , Deiziel DJ. Laparoscopic Ultrasound as the primary method for bile duct imaging during cholecystectomy , Surgical Endoscopy: 20: 208-213
2. Yao et al. Assessment of common bile duct using Laparoscopic ultrasound during laparascopic cholecystectomy . Surg Laparosc Endosc Percutan Tech. 2009 Aug:19(4):317-20 .
3. McFarlane et al . Selective Operative cholangiography in the performance of laparoscopic cholecystectomy . Int J Clin Pract Nov; 59(11):103-3
4. Martin A. Makary, MD, MPH,* Mark D. Duncan, MD,* et al . The Role of Magnetic Resonance Cholangiography in the Management of Patients With Gallstone PancreatitisAnn Surg. 2005 January; 241(1): 119–124
5. Koo KP, Traverso LW. Do preoperative indicators predict the presence of common bile duct stones during laparoscopic cholecystectomy? Am J Surg. 1996;171:495–499.
6. Robertson GSM, Jagger C, Johnson PRV, et al. Selection criteria for preoperative endoscopic retrograde cholangiopancreatography in the laparoscopic era. Arch Surg. 1996;131:89–94.
7.Hochwald SN, Dobryansky M, Rofsky NM, et al. Magnetic resonance cholangiopancreatography accurately predicts the presence or absence of choledocholithiasis. J Gastrointest Surg. 1998;2:573–579.
8. Bilbao MK, Dotter CT, Lee TG, et al. Complications of endoscopic retrograde cholangiopancreatography (ERCP): a study of 10,000 cases. Gastroenterology. 1976;70:314–320.
9. Stuart Mercer,  Sukhpal Singh, and Iain Paterson2 Selective MRCP in the management of suspected common bile duct stones , HPB.  2007; 9(2): 125–130.
10-Abboud PA, Malet PF, Berlin JA, Staroscik R, Cabana MD, Clarke JR, Shea JA, Schwartz JS, Williams SV. Predictors of common bile duct stones prior to cholecystectomy: a metaanalysis. Gastrointest Endosc 1996; 44: 450-455
11-Barkun AN, Barkun JS, Fried GM, Ghitulescu G, Steinmetz O, Pham C Meakins JL, Goresky CA. Useful predictors of bile  duct stones in patients undergoing laparoscopic cholecystectomy. McGill Gallstone Treatment Group. Ann Surg 1994;   220: 32-39
12-Cohen ME, Slezak L, Wells CK, Andersen DK, Topazian M. Prediction of bile duct stones and complications in gallstone  pancreatitis using early laboratory trends. Am J Gastroenterol 2001; 96: 3305-3311

Source(s) of Funding

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Competing Interests

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