الفهرس 
Material and methodsOnly 14 pages are availabe for public view
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Abstract
Choledocholithiasis occurs in a variety of circumstances most
frequently in patients with co-existing stones in the gall bladder, or as
residual stones following cholecystectomy, it may also occur in stagnant
bile as in papillary stenosis or proximal to benign common bile duct
stricture. Common bile duct stones may remain asymptomatic for long
periods of time , but acute pancreatitis , cholangitis and obstructive
jaundice may develop.
The foundation of modem common bile duct exploration was laid by
Ludwig Courvoisier in 1890 , with the first successful removal of
common bile duct stones . For generations since this historical event,
operative exploration of the common bile duct at the time of
cholecystectomy has been considered the benchmark to which all other
treatment modalities are compared .
The recent dramatic shift from open to laparoscopic cholecystectomy
has stimulated a reappraisal of the approach to choledocholithiasis. For
surgeons who perform laparoscopic cholecystectomy but not
laparoscopic common bile duct exploration, preoperative diagnosis of
choledocholithiasis is essential to schedule these patients for either the
open technique or bile duct clearing ER.C.P .
Accordingly, this work is a trial to evaluate the efficacy and safety of
E.R.C.P and laparoscopic cholecystectomy in the management of
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patients with chronic calcular cholecystitis and suspeccted
choledocholithiasis.
Fifty patients with chronic calcular cholecystitis, 29 females and 21
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males ,with age ranging between 22 - 70 years (mean 45.46 + 10 years)
comprised the patients of the study. Suspected choledocholithiasis in
these patients was a result of clinical, laboratory or ultra-sonographic
data. Choledocholithiasis was either proved or discarded byE.R.c.p .
Meanwhile , therapeutic stone extraction was attempted in the same
session by dormia basket, lithotripsy or balloon extraction. Being sure
that the Common bile duct was clear of stones laparoscopic
cholecystectomy was performed eventualy in a period ranging from two
days to two weeks .
Classification of patients according to. risk factors of
choledocholithiasis into groups was done and the percent of actual
verification of common bile duct stones ( total 30 patients) was :
- Group A: Clinical jaundice (9J. 7%) .
- GroupB: Gall stone pancreatitis (50%) .
- Group C: Elevated liver function tests & normal duct size (58.3%) .
- Group D: Stones seen in ~.B.D by ultrasound (100%).
- Group E: Elevated liver functions & dilated C.B.D by VIS (92.3%) .
After overcoming the different endoscopic difficulties encountered,
common bile duct clearance was achieved in 25 out of 30 patients
(83.3%) all the failed cases, 5patients (16.7%) were managed by open
surgery. Complications to E.R.c.p (32 endoscopic sphincterotomies)
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140 were : pancreatitis III two cases (6.25%) who were managed
conservatively , cholangitis in three cases (9.4%) who were also
managed conservatively and bleeding due to endoscopic sphincterotomy
in three more patients (9.4%) with only one patient managed
conservatively and the other two resorted to open surgery for arrest of
beeding and also clearing the duct stones .
Comparative analysis of the diagnostic variables revealed that failure
of E.R.C.P in achieving duct clearance was associated with significantly
older age ,more associated fever , higher total serum bilirubin &
hypertension.
Laparoscopic cholecystectomy was plarmed for 46 patients in the
study, as one of the failed five cases by E.R.CP was actualy discovered
postoperatively . Difficulties encountered were related to insuffiation
(4.3%) , dissection (10.8%) , bleeding control (4.3%), spilled stones
(6.5%) & gall bladder extraction (6.5%). Conversion to open surgery
was done in five patients (10.9%) due to: severe chronic adhesions with
the gall bladder (6.5%), empyema of the gall bladder (2.2%) & bleeding
from the gall bladder bed (2.2%) .
Comparative analysis of the diagnostic variables revealed that failure
of laparoscopic cholecystectomy was associated with significantly older
age , higher total serum bilirubin , more associated fever ,obesity,
shistosomiasis and hypertension . Postoperative complications occured
in the form of : wound infection (12.2%) ,Atelectasis & pneumonia
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(4.9%) , urinary retension (2.4%) , prolonged ileus (2.4%) , D.V.T
(4.9%), myocardial infarction (2.4%) & retained C.B.D stones (2.4%).
from the results of this study it could be concluded that the
combination of E.R.c.p and laparoscopic cholecystectomy in the
management of suspected choledocholithiasis in patients with chronic
calcular cholecystitis seems an adequate Protocol whenever possible.
Our success rate of 80% seems an encouraging outcome when compared
to the open common bile duct exploration which still remains the gold
standard therapy for proven cases of choledocholithiasis . Meanwhile,
the reduction of postoperative hospital stay and earlier patients’ return to
the normal daily activities together with minimal invasion and tissue
damage induced add more advantages to this Protocol.