الفهرس 
TitleOnly 14 pages are availabe for public view
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Abstract
Choledocholithiasis is a common problem with an incidence of about 15-20% among patients with gall bladder stones. Multiple philosophical debates are still in question regarding the management of CBD stones with associating gallstones. Two main philosophies address this topic, the first is the endoscopic management of CBD stones together with laparoscopic cholecystectomy. The second philosophy is the total laparoscopic management of both CBD stones and gall stones. Our thesis was formed of experimental and clinical phases. The clinical phase of the study included one hundred patients having concomitant common bile duct and gall stones admitted to the Surgical Department at the Medical Research Institute Hospital, University of Alexandria. They were randomly allocated into two equal-sized groups where group A included 50 patients who had a laparoscopic CBD exploration and laparoscopic cholecystectomy, while group B included 50 patients who had ERCP followed by laparoscopic cholecystectomy. The primary aim of the study was to assess the success rate of each technique in achieving biliary clearance and a successful cholecystectomy. Other parameters measured were the total operative duration, total hospital stay, conversion to other procedures, and technique-related complications.
Both groups were well matched regarding the demographic data, presenting symptoms, comorbidities, and laboratory findings. Pain was the most common presenting symptom in 88% and 92% of patients in groups A and B respectively.
The biliary ultrasonic assessment was matched in both of our studied groups where the common bile duct was normal in diameter in 12% of group A patients and 6% of group B patients and dilated in 14% of group A patients versus 20% of group B patients. Dilated CBD with a documented stone(s) inside was identified in 74% of patients in both groups. Intrahepatic biliary dilatation was found in 92% of group A patients and 96% of group B patients. The mean size of the largest CBD stone was 13.49 ± 5.03 mm in group A and 12.09 ± 3.12 mm in group B, whereas the mean CBD diameter was 14.71 ± 4.89 mm in group A and 13.69 ± 3.12 mm in group B. A single CBD stone was detected in 44% of patients of both groups, whereas stones more than five were counted in 22% of group A patients and 18% of group B patients.
Successful CBD clearance together with successful laparoscopic cholecystectomy was insignificantly different between both groups where it reached 90% (45 patients) of group A (LCBDE + LC) and 86% (43 patients) of group B (ERCP + LC).
However, both total procedure duration and hospital stay were significantly longer in group A than in group B patients, where the total procedure duration in group A was 141.28 ± 51.29 minutes versus 98.98 ± 50.06 minutes among group B patients. Total hospital stay was 2.36 ± 1.31 days versus 1.86 ± 1.73 days in groups A and B respectively.
On contrary, group A had a statistically significantly lower number of procedures per patient with a mean of 1.04 ± 0.2 versus 1.88 ± 0.52 in group B patients.
Summary, Conclusions and Recommendations
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We experienced no mortalities in both groups and the morbidity rate was well-matched in both groups (40% in group A versus 32% in group B). According to the Clavien-Dindo classification, complications were mostly of grade I (85% in group A vs 68.8% in group B). Grade II complications occurred in 5 % of group A patients and 25% of group B patients, while grade III complications occurred in 10% of group A patients and 6.3% of group B patients. The most common complications in group A patients were bile leak (10 patients) and superficial surgical site port site infection (8 patients) while in group B patients post-ERCP pancreatitis (6 patients) and port site infection (5 patients) were the most common complications.
Both laparoscopic common bile duct exploration and ERCP followed by laparoscopic cholecystectomy were equally effective and safe in the management of concomitant common bile duct and gallbladder stones. ERCP + LC had the advantages of shorter total procedure duration and hospital stay while LCBDE had the advantage of the lower needed number of procedures per patient.
In the experimental phase, we were assessing the protective effect of Ursodeoxycholic acid administration in preventing gallstones formation. Thirty female mice 7-8 weeks old were divided into 3 equal-sized groups where mice in group A were fed normal laboratory chow while in group B, mice were fed a lithogenic diet. Mice in group C were fed a lithogenic diet and administered Ursodeoxycholic acid via oral gavage in a dose of 30 mg/kg/day. After 12 weeks all mice were euthanized and their gallbladders were examined grossly and microscopically. We found gallstones grossly in 90% of mice fed the lithogenic diet alone and no stones in both the control group (fed ordinary chow) and group C (Mice fed lithogenic diet + UDCA). This finding emphasized the protective role of Ursodeoxycholic acid against cholelithiasis.
6.2 Conclusions and Recommendations
Laparoscopic common bile duct exploration with cholecystectomy was as effective and safe as Endoscopic Retrograde Cholangio Pancreatography in the management of common bile duct stones.
ERCP had the advantages of shorter total procedure duration and hospital stay.
Laparoscopic CBD exploration had the advantage of fewer interventions needed for each patient.
Longer follow-up is recommended after this study to allow for the detection of recurrent stones after both techniques.
Wider implementation of both laparoscopic and endoscopic guided lithotripsy is recommended in further studies to reduce the rate of conversions and permit the management of too large or impacted CBD stones.
Cost-effectiveness and factors affecting operative duration need to be measured thoroughly in a dedicated study.
Ursodeoxycholic acid was effective in preventing gallstones in mice, and the lithogenic diet we adopted had enabled us to reach an animal model for gallstones.