Operative choledochoscopic laser lithotripsy for impacted intrahepatic gallstones: a novel surgical approach.

INTRODUCTION: Occasionally patients present with hepatic duct stones or impacted common bile duct stones that either fail or are not amenable to endoscopic retrograde cholangiopancreatography (ERCP) extraction. More troublesome are patients with prior surgeries resulting in altered anatomy that makes traditional endoscopic extraction of ductal stones very difficult. We present a novel approach to these ductal stones using a combination of surgery, biliary endoscopy, and laser lithotripsy. METHODS: We report on five patients with ductal stones that either failed ERCP or were not candidates for ERCP extraction. Data was collected via chart review with Institutional Review Board approval. RESULTS: The average age of patients was 70.1 years. All patients presented with hepaticolithiasis and symptoms of cholangitis including elevated liver function tests and recurrent fever and chills. Patients had a mean of 2.8 failed ERCP or percutaneous attempts at stone clearance (range 2-4). A combination of surgery and intraoperative biliary endoscopy with laser lithotripsy (holmium laser) was used in all patients. In four patients the lithotripter was introduced via a choledochotomy or hepaticodochotomy. One patient had previously undergone a Roux-en-Y hepaticojejunostomy and was found to have a large hepatic duct stone sitting above a strictured anastomosis. Access was gained via an enterotomy in the Roux limb. Complete stone clearance was obtained in all patients. Average operative time was 349 min. All patients have normal liver function tests (27-36 month follow-up). CONCLUSION: Laser lithotripsy has been described as an adjunct to ERCP in the past for stones refractory to balloon or basket retrieval. The combination of a surgical enterotomy, biliary endoscopy, and laser lithotripsy provides a novel approach to treat patients with large intrahepatic stones who are not candidates for or have failed ERCP.

Rural versus non-rural differences in surgeon performed endoscopy: results of a national survey.

The ongoing decline in the number of general surgeons practicing in rural areas of the United States is concerning. Existing data show that rural surgeons perform a broad spectrum of cases including procedures that are not considered to be in the repertoire of most general surgeons. In particular, rural surgeons seem to be performing a sizeable number of endoscopic procedures. A sixty-item survey was mailed to 1700 rural surgeons while a random sample of 154 urban surgeons were telephoned and administered the same questionnaire. The general surgeons were identified using a list obtained from the American Medical Association Masterfile. The response rate was 25 per cent and 74 per cent among rural and nonrural surgeons respectively. Seventy four per cent of rural surgeons performed more than 50 flexible endoscopies a year in contrast to 33 per cent of nonrural surgeons (P < 0.05). Approximately 42 per cent of rural surgeons reported doing more than 200 procedures annually, whereas only 12 per cent of the nonrural surgeons did so. Additionally, 63 per cent of rural surgeons wished they had further training in endoscopy before starting practice as compared with 46 per cent (P < 0.05) of nonrural surgeons. Rural surgeons perform flexible endoscopy at a much higher rate than their nonrural counterparts. The majority of rural surgeons feel they would have benefited from additional flexible endoscopy training before entering practice.