Randomized clinical trial of intraoperative endoscopic retrograde cholangiopancreatography versus laparoscopic bile duct exploration in patients with choledocholithiasis.

BACKGROUND: Various minimally invasive approaches exist for the management of choledocholithiasis at the time of laparoscopic cholecystectomy. The aim of this study was to compare endoscopic retrograde cholangiopancreatography (ERCP) with laparoscopic bile duct exploration (LBDE) and test the hypothesis that intraoperative ERCP is no different to LBDE in terms of rate of bile duct clearance or retained stones. METHODS: Eligible patients with choledocholithiasis undergoing emergency laparoscopic cholecystectomy were randomized to intraoperative ERCP or LBDE in a 1 : 1 ratio. The primary outcomes were rates of bile duct clearance and retained stones. Secondary outcomes were postprocedure complication rate, mortality rate, postoperative length of hospital stay, conversion to open surgery rate, procedural time and total duration of surgery. RESULTS: Some 104 patients were randomized, and 52 patients in each group were included in an intention-to-treat analysis. Duct clearance rates were 87 per cent for patients who had intraoperative ERCP and 69 per cent for those in the LBDE group (P = 0·057). The rate of retained stones was lower in the ERCP group than in the LBDE group: 15 versus 42 per cent respectively (P = 0·004). Median postoperative length of stay was shorter with ERCP (2 days versus 3 days for LBDE; P = 0·015). CONCLUSION: Intraoperative ERCP is more effective than LBDE in terms of minimizing the rate of retained stones in patients with choledocholithiasis undergoing emergency laparoscopic cholecystectomy. REGISTRATION NUMBER: ACTRN12613000761763 (http://www.anzctr.org.au/).

Bilateral aneurysms of the extracranial internal carotid artery presenting as vocal fold palsy.

Bilateral extracranial internal carotid aneurysms are very rare, though well documented. We report a case of bilateral extracranial internal carotid aneurysms presenting with vocal fold paralysis, which we believe to be the first.

Technical note: femoral angiography using the reverse shuffle technique.

We report our findings using the "reverse shuffle" technique of stepping table femoral angiography. This technique represents a simple modification of the conventional stepping table sequence entailing a reverse table movement allowing acquisition of early and late films in the distal positions. It was developed in order to minimize the number of runs required in each examination. In a retrospective study 52/53 (98%) of angiograms using the reverse shuffle technique required only a single run compared with 30/51 (58%) using the conventional technique. We believe that the reverse shuffle should be used where possible when stepping table angiography is performed. Furthermore, the incorporation of a reverse table movement may also be advantageous in angiography using automated digital subtraction angiography (DSA) stepping systems.

Mirizzi syndrome treated by percutaneous stone removal.

We report a case of Mirizzi syndrome due to a cystic duct stone occurring in a 66-year-old man in the presence of multiple debilitating medical conditions which precluded surgery. The patient was successfully treated by percutaneous stone removal and made a swift and uneventful recovery. This is the first report of Mirizzi syndrome due to a ductal stone being treated in this manner.