BACKGROUND: Bile duct stones affect 10% of patients who undergo a cholecystectomy and therefore represent a major health problem. Laparoscopic common bile duct exploration, endoscopic sphincterotomy, and open surgical choledocholithotomy are the three available methods for dealing with choledocholithiasis. Though many trials and reviews have compared all three strategies, a list of indications for defined patient profiles is lacking. METHODS: We employed the RAND Corporation/UCLA Appropriateness Method (RAM) to evaluate the three procedures for bile duct stone clearance. An expert panel judged appropriateness after a comprehensive bibliography review, a first-round private rating of 108 different clinical situations, a consensus meeting, and a second round of definitive rating. A list of indications for each procedure was statistically calculated. RESULTS: A consensus was reached for 41 indications (38%). The endoscopic approach was always appropriate for preoperatively diagnosed bile duct stones and inappropriate for patients with single intraoperative detected stones causing cholangitis and bile duct dilatation. Laparoscopic bile duct exploration was appropriate for preoperatively diagnosed choledocholithiasis if patients had not undergone a previous cholecystectomy and no signs of cholangitis were detected. The laparoscopic approach was also appropriate for intraoperatively incidentally detected stones, except for septic patients with poor performance status and multiple calculi. Laparoscopic bile duct clearance was judged inappropriate for septic patients with poor performance status and absence of bile duct dilatation. Open surgery was appropriate in all patients with intraoperative diagnosis of choledocholithiasis and cholangitis and in septic patients with bile duct dilatation. There was no clinical situation in which open surgery was appropriate when bile duct stones were preoperatively diagnosed. CONCLUSIONS: There is still uncertainty with respect to the management of choledocholithiasis, showing the need for further investigation. The RAM helps to elucidate appropriateness for the different treatment options in specific clinical settings.
BACKGROUND: Bile duct stones affect 10% of patients who undergo a cholecystectomy and therefore represent a major health problem. Laparoscopic common bile duct exploration, endoscopic sphincterotomy, and open surgical choledocholithotomy are the three available methods for dealing with choledocholithiasis. Though many trials and reviews have compared all three strategies, a list of indications for defined patient profiles is lacking. METHODS: We employed the RAND Corporation/UCLA Appropriateness Method (RAM) to evaluate the three procedures for bile duct stone clearance. An expert panel judged appropriateness after a comprehensive bibliography review, a first-round private rating of 108 different clinical situations, a consensus meeting, and a second round of definitive rating. A list of indications for each procedure was statistically calculated. RESULTS: A consensus was reached for 41 indications (38%). The endoscopic approach was always appropriate for preoperatively diagnosed bile duct stones and inappropriate for patients with single intraoperative detected stones causing cholangitis and bile duct dilatation. Laparoscopic bile duct exploration was appropriate for preoperatively diagnosed choledocholithiasis if patients had not undergone a previous cholecystectomy and no signs of cholangitis were detected. The laparoscopic approach was also appropriate for intraoperatively incidentally detected stones, except for septicpatients with poor performance status and multiple calculi. Laparoscopic bile duct clearance was judged inappropriate for septicpatients with poor performance status and absence of bile duct dilatation. Open surgery was appropriate in all patients with intraoperative diagnosis of choledocholithiasis and cholangitis and in septicpatients with bile duct dilatation. There was no clinical situation in which open surgery was appropriate when bile duct stones were preoperatively diagnosed. CONCLUSIONS: There is still uncertainty with respect to the management of choledocholithiasis, showing the need for further investigation. The RAM helps to elucidate appropriateness for the different treatment options in specific clinical settings.
Authors: Graeme J Poston; René Adam; Steven Alberts; Steven Curley; Juan Figueras; Daniel Haller; Francis Kunstlinger; Gilles Mentha; Bernard Nordlinger; Yehuda Patt; John Primrose; Mark Roh; Philippe Rougier; Theo Ruers; Hans Joachim Schmoll; Carlos Valls; Nick Jean-Nicolas Vauthey; Marleen Cornelis; James P Kahan Journal: J Clin Oncol Date: 2005-10-01 Impact factor: 44.544
Authors: A Cuschieri; E Lezoche; M Morino; E Croce; A Lacy; J Toouli; A Faggioni; V M Ribeiro; J Jakimowicz; J Visa; G B Hanna Journal: Surg Endosc Date: 1999-10 Impact factor: 4.584
Authors: Kristin M Sheffield; Yimei Han; Yong-Fang Kuo; Courtney M Townsend; James S Goodwin; Taylor S Riall Journal: J Am Coll Surg Date: 2012-02-25 Impact factor: 6.113