الفهرس 
Material and methodsOnly 14 pages are availabe for public view
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Abstract
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CONCLUSION
Stones occur in the C.B.D. in a variety of circumstances most frequently in patients with co-existing stones in the gall bladder, or as residual stones following cholecystectomy. However, choledocholithiasis may also occur in the stagnant bile as in proximal to benign bile duct stricture or as in papillary stenosis. The incidence of choledocholithiasis increases with age. Stones in the C.B.D may remain asymptomatic for long periods of time, but acute pancreatitis, cholangitis and obstructive jaundice may develop.
By the late 1980s, E.R.C.P seemed to become the option of choice• for drainage of jaundice and extraction of C.B.D stones. More recently, laparoscopic cholecystectomy has been encroaching on open chole-cystectomy as the procedure of choice for gall bladder removal.
This work is a trial to compare the open traditional surgery versus the combination of therapeutic E.R.C.P followed by L.C., regarding its efficacy, convalescence, morbidity, and mortality of patients with calcular obstructive jaundice.
Fifty patients with calcular obstructive jaundice, 32 females and 18 males, with age ranging between 22-70 years (mean 45.46 ± 11 years) comprised the patients population of this study. Diagnosis was achieved after proper clinical assessment, full set of laboratory investigations,
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abdominal ultrasonography, and diagnostic E.R.C.P. Then, the patients were randomized without any specifications into two equal groups: A and B
Patients belonging to group (A) were managed by the traditional open surgical procedure, while management of group B patients was attempted by endoscopic sphincterotomy and stone extraction followed two weeks later by laparoscopic cholecystectomy.
In group (B) patients, after overcoming the different endoscopic difficulties encountered, complete C.B.D clearance was achieved in 23 patients (92%) with two complications, bleeding in one patient managed endoscopically and pancreatitis in another one managed conservatively. The failed two cases (8%) were managed by open surgery.
Laparoscopic cholecystectomy was attempted only in the 23 patients with successful endoscopic C.B.D clearance. The difficulties encountered were related to insufflation, dissection, control of bleeding, spillage of stones, and extraction of stone-laden gall bladder. The procedure succeeded in 19 patients (82.6%) and the remaining 4 were converted to open surgery.
Comparative analysis of group (B) diagnostic variables revealed that failure of L.C. was associated with significantly older age, higher total serum bilirubin, more associated fever, hepatomegaly, tender right hypochondrium, and severe chronic inflammation of the gall bladder detected by ultrasound.
Successful cases in group (B) showed a significant reduction in operative time, thus risks of general anesthesia and possibly the theater
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expenses were reduced. Postoperatively, a marked difference in conva-lescence was observed as compared to that of group A patients. This was evident in :
The significant reduction in pain and requirements for analgesics. The significant reduction in the duration of antibiotics used.
The significant reduction in the duration of ileus and fluid therapy with rapid return to oral feeding.
The significant reduction in the requirements for nasogastric tubes, drains and T-tubes and consequently their complications.
The significant earlier ambulation out of bed.
The significant reduction in post-operative hospital stay.
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Postoperative morbidity occurred in the form of :
*Wound infections which were markedly reduced in group (B) with reduced requirements for dressing, local, and systemic antibiotics.
*Burst abdomen which occurred in one patient of group (A).
*Prolonged postoperative fever with reduced incidence in group (B) patients.
Mortality was encountered in one patient, belonging to group(A) out of postoperative renal failure.
from the results of this study it could be concluded that;
*The combination of E.R.C.P and L.C. seems quite feasible protocol for the management of calcular obstructive jaundice with a total success rate of 76% and a final outcome similar to that of open surgery. This way of management reduces the operative time and postoperative hospital stay, thus the expenses of treatment. The minimal invasion and tissue damage induced
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by this management were followed by rapid smooth convalescence, reduced morbidity and mortality.
Open surgery is preferable to L.0 in the following cases :
-Old cardiac patient.
-High serum bilirubin.
-Associated fever.
-Cases with signs of severe gall bladder inflammation proved by Tender-ness probe of ultrasonography.
Emergency biliary drainage is recommended in all patients presenting with calculus cholangitis who are severely ill with continuous fever for several days. Emergency nasobiliary drainage without E.S or after a limited E.S may be a safer treatment in patients with impending septic shock. We believe that a more conservative approach is justified in patients presenting with symptoms of mild cholangitis, restricting emergency biliary drainage for those who do not respond rapidly (<24 h) to antibiotics. Further emergency surgical or percutaneous biliary drainage should be performed immediately on patients in whom C.B.D stones are retained, or to E.S and drainage fails, especially if a stone is left impacted distally.
*Our patients underwent surgical intervention for three reasons: a diverticulum in the second part of the duodenum made an endoscopic approach more difficult, a big size primary C.B.D stones that defy conventional extraction method and the young patients with relatively small diameter of the C.B.D to avoid the risk of perforation.
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*Patients suffering from the problem of residual stones after cholecystectomy, must be assessed by the surgeon and endoscopist working in such a team to get the correct decision regarding either surgical or endoscopic methods, on clear stable, and scientific ground. Both methods proved to be complementary and not competitive.
*In that small group of patients with C.B.D stones and an intact gallbladder who are judged too ill or too frail to undergo cholecystectomy, endoscopic or radiological techniques for removal of ductal stones offer a less invasive but effective therapeutic option.
* Finally, in this era of the growing relevance of the economic issue in patient management, it is recommended to apply the E.S/L.0 approach as a primary line of management of calcular obstructive jaundice. These cases should be attempted by a competent endoscopist and a competent laparoscopic surgeon to achieve a high success rate. The future application of the advanced techniques in endoscopic lithotripsy and laparoscopic surgery may further raise the success rate of this approach.