Gallstone cholangitis

Surg Endosc (2002) 16:975-980 DOI: 10.1007/s00464-00t-9133-3 9 Springer-Verlag New York Inc. 2002 es Gallstone cholangitis and Other Interventional Techniques A 10-year experience of combined endoscopic and laparoscopic treatment L. Sarli, D. Iusco, G. Sgobba, L. Roncoroni Department of Surgery, Institute of General Surgery and Surgical Therapy, University of Parma, School of Medicine, 14 Via Giamsci, 43100 Parma, Italy Received: 16 July 2001/Accepted in final form: 8 November 2001/Online publication: 5 March 2002 Abstract Background." To date, no procedure has yet been identified as the gold standard for the treatment of gallstone cholangitis in the laparoscopic era. Methods: The data of 109 consecutive patients with acute cholangitis were prospectively entered into a computerized database. All patients were managed according to a standard protocol. The main treatments were endoscopic retrograde cholangiography (ERC) combined with endoscopic sphincterotomy (ES), followed by interval laparoscopic cholecystectomy (LC). Patients in whom ERC or endoscopic stone clearance failed were managed by emergency open common bile duct exploration. LC was performed with a standardized four-cannula technique. The mean duration of surgery, conversion rate, and postoperative outcome of these patients were evaluated. Results." ERC was successful in 103 patients (94.5%). In five of these patients (4.8%), no bile duct stones were found. The 98 patients (95.2%) with common bile duct stones were referred for ES. The bile duct stones were successfully removed after ES in 93 cases (94.9%). The overall failure rate of ERC and ES for choledocholithiasis was 10.1%. Self-limiting pancreatitis occurred in four patients (4.3%). Overall, two of the 109 patients died (1.8%). After ES, 81 patients underwent LC. LC was performed successfully in 74 patients (91.3%). Conversion to open surgery was required in seven patients (8.7%). The morbidity rate after cholecystectomy was 7.4%; the morbidity rate after open bile duct exploration was 36.4% (p<0.05). Fifteen patients were managed conservatively after initial endoscopic management of their cholangitis. The overall incidence of recurrent biliary symptoms was significantly higher among patients with gallbladder in place than for patients who underwent cholecystectomy (38.5% vs 1.5%, p <0.001). Correspondence to: L. Sarli Conclusions: ES followed by LC is a safe and effective approach for the management of gallstone cholangitis; cholecystectomy should be performed in patients with gallstone cholangitis unless the operative risk is extremely high. These high operative risk patients and those who refuse surgery after ES should be warned that they are at high risk for recurrent biliary symptoms. Key words: Gallstone cholangitis -- Common bile duct stones -- Endoscopic retrograde cholangiography -- Endoscopic sphincterotomy -- Laparoscopic cholecystectomy In Western populations, acute cholangitis occurs in 6-9% of patients affected by gallstone disease [12]. For many years, open exploration and clearance of the bile duct was the standard treatment, and the mortality rate ran as high as 40% for patients with severe cholangitis [31, 32]. The introduction of endoscopic sphincterotomy (ES) lowered the mortality rate to between 0.4% and 7% [14, 15]; therefore, endoscopic management, followed by elective open surgery, became a standard approach [13]. With the rapid acceptance of laparoscopic cholecystectomy (LC), open surgery has been relegated to situations in which minimally invasive management has failed [24]. The management of choledocholithiasis has been influenced by the increasing success of minimally invasive methods. Most surgeons now try to avoid open duct exploration when bile duct stones coexist with gallbladder stones. Thus, some studies have focused on the efficacy and safety of laparoscopic bile duct exploration [6, 8, 11, 19, 28], whereas others have focused on the value of ES before, during, and after LC [2, 25]. However, few studies have specifically evaluated the efficacy of the mini-invasive approach for gallstone

976 Symptoms of gallstone cholangitis + Physical examination Urgent US Blood culture + IV antibiotics failed 4 ERC Failed ES ~ Successful Open Surgery ** For patients with unstable haemodynamic status or expected difficulty of stone removal, initial drainage was obtained by nasobi iax~, drainage or, in more recent years (1996-2001), by the insertion of an endoorosthesis. LC Fig. I. Planned algorithm for the therapeutic management of patients affected by gallstone cholangitis. US, ultrasonography; IV, intravenous; ERC, endoscopic retrograde cholangiography; LC, laparoscopic cholecystectomy: ES, endoscopic sphincterotomy. cholangitis [22], and none have attempted to determine which of the different mini-invasive methods of management is the most effective for patients with cholangitis. The choice between these different methods is complex because of the multidisciplinary character of the treatments, the variation in availability from one center to another, and the varying experience of the surgeon in each of the available techniques of treatment. Since no randomized trials are available to prove which approach is preferable, it would be useful to examine the results that have been achieved with these different techniques. Therefore, we decided to analyze the prospectively collected results of our technical algorithm for the endoscopic-laparoscopic treatment of patients with gallstone cholangitis. Patients and methods During the 10-year period between January 1991 and January 2001, 109 consecutive patients with acute cholangitis due to gallstone disease were admitted to our institute. Patients with intrahepatic ductal stones or previous cholecystectomy were excluded from this study because the treatment of their disease was not included in the technical algorithm we wanted to analyze. There were 51 men (47%) and 58 women (53%). The mean age was 66.8 years (SD, 12.1; range, 28-94). The diagnosis of acute cholangitis was based on a combination of upper abdominal pain, jaundice, chills, and fever (temperature > 37.5~ [13]. Twenty nine patients (35%) had severe cholangitis, defined by the presence of septic shock, mental confusion, or persistent high fever despite antibiotic treatment [13]. The data of 109 consecutive patients with acute cholangitis were entered into a computerized database. Preoperative and intraoperative data were documented systematically and prospectively. Surgeons recorded the following information: clinical history, baseline characteristics, indications and results of perioperative evaluation, details of surgical technique and intraoperative findings, hospital course, and postoperative follow-up findings. All patients were managed according to a standard protocol. The algorithm for therapeutic management is shown in Fig. 1. Patients began fasting and were given intravenous fluid after admission. After routine blood tests, including blood culture, a broad-spectrum intravenous antibiotic was administered immediately after a clinical diagnosis of acute cholangitis was made. Urgent ultrasonography was performed to confirm the diagnosis. Patients underwent endoscopic retrograde cholangiography (ERC) combined with ES within 72 h of admission. For patients with severe cholangitis, emergency ERC was performed. All endoscopic procedures were performed at our hospital in the usual manner under pharyngeal anesthesia and intravenous sedation administered by two endoscopists with > 5 years of experience in diagnostic and therapeutic ERC. For patients with unstable hemodynamic status or expected difficulty of stone removal, initial drainage was obtained by nasobiliary drainage or--in more recent years (1996-2001)--by the insertion of an endoprosthesis using a polyethylene double pigtail catheter to control the sepsis, followed by ES and stone removal in an elective session. Otherwise, ES and stone removal were performed in the same session. Patients in whom ERC or endoscopic stone clearance failed were managed by emergency open common bile duct exploration. For patients in whom ES was successful, LC was offered within 1 week of the endoscopic procedures. High-risk patients, such as elderly patients with severe comorbid illnesses, and patients who refused surgery were managed conservatively with regular follow-up to monitor for any recurrent biliary symptoms. LC was performed with a standardized four-cannula technique [I0]. Low-molecular-weight heparin prophylaxis was given to all patients. Intraoperative cholangiography was performed whenever the surgeon was in doubt as to the biliary anatomy or bile duct clearance. A drain was used in all cases. The operating time was calculated from the start of incision until the last suture. The outcome of ERC, complications of ERC with ES and LC, and the rate of conversion from LC to an open procedure were recorded. Postoperative complications were evaluated according to a recently developed classification of surgical complications that has a severity scale comprising four grades [5] (Table 1). All patients were offered regular follow-up in the outpatient clinic. Patients were seen at intervals of 3 months in the 1st year, and then every 6 months to 1 year. Patients with recurrent biliary symptoms were readmitted investe for possible recurrent bile duct stones. Because of the possibility of biliary disease, patients who did not attend regular follow-ups were instructed to notify a physician from our team about any clinical symptoms or signs or any laboratory or imaging data that their family physician might have obtained. Moreover, for those who did not attend regular follow-ups, a telephone interview with the patient (or a relative if the patient had died) for any recurrent biliary symptoms was conducted by the principal investigator. The results of ERC with ES for retained stones were recorded. Statistical analyses were conducted with SAS procedures (SAS Program Institute, Cary, NC, USA). Continuous data were expressed as mean + standard deviation (SD). Fisher's exact test and the Wilcoxon test were used when appropriate. A p value < 0.05 was considered significant.

977 Table 1. Classification of surgical complications Grade I II iia lib IIi IV Description Non-life-threatening, no lasting disability, does not extend hospital stay to more than twice the mean hospitalization within the same patient group Potentially life-threatening, but without residual disability Does not require invasive procedure, but extends hospital stay to more than twice the mean hospitalization within the same patient group Requires invasive procedures Causes residuals disability Deaths due to complications Table 2. Comparison of results of 81 laparoscopic cholecystectomies (LC) after endoscopic sphincterotomy (ES) for cholangitis and results of 11 open common bile duct explorations (CBDE) according to the severity of cholangitis (severe, nonsevere) ES + LC (81) (n = 81) Open CBDE (n = I1) Mean age (yr SD) 64.5 11.3 66.7 11.1 % ASA score III/IV 38% 73% Severe (n = 24) Nonsevere (n = 57) Severe (n = 3) Nonsevere (n = 8) Postoperative outcome Uncomplicated 87.5% 94.7% 66.6% 62.5% Grade I complications 8.3% 3.6% 33.3% 25% Grade IIa complications -- 1.7% -- -- Grade IIb complications 4.2% -- -- 12.5% ES, endoscopic sphincterotomy; LC, laparoscopic cholecystectomy; CBDE, common bile duct exploration; SD, standard deviation; ASA, American Society of Anesthesiologists Results The 109 patients in the study were referred for preoperative ERC. Billroth II gastrectomy prevented cannulation of the papilla in six cases (5.5%). For these six patients, open bile duct exploration was considered necessary. Open duct exploration confirmed bile duct stones in all these patients. ERC was successful in 103 patients (94.5%). In five these patient (4.8%), no bile duct stones were found, presumably owing to spontaneous stone passage. The 98 patients (95.2%) with common bile duct stones were referred for ES. ES failed in five of these 98 patients (5.1%). In three cases, ES was not attempted because of the presence of a duodenal diverticulum. In one case, several endoscopic sessions were insufficient to obtain bile duct clearance; and in one case stone extraction failed because of ductal stone impact For these latter five patients, LC was cancelled and emergency open surgery with choledochotomy was performed. Clearance of the common bile duct was achieved in all patients who underwent open bile duct exploration. The overall failure rate of ERC and ES for choledocholithiasis was 10.1%. The bile duct stones were successfully removed after ES in 93 cases (94.9%). To achieve complete ductal clearance of stones, 11 patients needed repeated endoscopic sessions (median, three; range, two to four). In seven cases, bile duct decompression was achieved by nasobiliary drainage (three patients) or by temporary stenting (four patients). Subsequently, ES was performed in all seven cases. Self-limiting pancreatitis oc- curred in four patients after ES and stone extraction (4.3%). These patients needed supportive therapy alone; all of them underwent LC 1 week later and enjoyed an uncomplicated course. Overall, two of the 109 patients died (1.8%). Both deaths occurred in patients with persistent septic shock caused by severe cholangitis despite emergency ES with bile duct stone extraction. The mortality rate among patients with severe cholangitis was 6.8%, whereas the mortality rate for patients with not severe cholangitis was nil. After ES, 81 patients underwent LC. LC was performed successfully in 74 patients (91.3%). Mean duration of LC was 57 min (range, 30-120). Conversion to open surgery was required in seven cases (8.7%) due to dense adhesions (five patients) or intraoperative bleeding (two patients). No patient underwent intraoperative cholangiography during LC. Morbidity rate after cholecystectomy was 5.3% for patients with the nonsevere form of cholangitis and 12.5% for patients with severe cholangitis; the overall morbidity rate after cholecystectomy was 7.4% (Table 2). A total of 11 patients underwent open common bile duct exploration, including the five who had emergency open surgery. The median operating time was 135 min (range, 100-180). The morbidity rate was 36.4% (Table 2) (25% for patients with the nonsevere form of cholangitis and 33.3% for patients with severe cholangitis}--significantly higher than the 7.4% among the 81 patients who underwent laparoscopic surgery with or without conversion (p < 0.05). Altogether, 92 patients underwent definitive surgical treatment without any operative mortality. The mean +

978 Table 3. Follow-up status of patients with and without cholecystectomy Alive with no recurrent biliary symptoms 62 (88.6) Recurrent cholangitis 1 (1.4) Recurrent common bile duct stones 1 (1.4) Biliary colic Deaths from unrelated condition 7 (10) n.s., not significant Date given as n (%) With cholecystectomy (n = 70) Without cholecystectomy (n = 13) p value 3 (23.1) 0.001 2 (15.4) n.s 3 (23.1) 0.0! 2 (15.4) 0.05 5 (38.5) 0.05 SD age of these patients was 64.8 + 11.1 years (range, 24-78). Fifteen patients, with a mean age of 77 + 7 years (range, 69-94), were managed conservatively after initial endoscopic management of cholangitis. Six patients were considered fit for LC after ES and common bile duct clearance but refused surgical intervention. The other nine patients had severe comorbid illnesses; thus they were considered to be at high risk for surgery and were managed conservatively after the endoscopic management of their cholangitis. Follow-up data were available for 83 of the 107 patients who survived the initial cholangitis, including 70 patients who had undergone cholecystectomy and 13 patients with gallbladder in place. Forty-seven patients had regular follow-ups in the outpatient clinic. For the remaining 36, telephone interviews were successfully conducted. When the end of follow-up was taken as the patient's death, the last follow-up was 39 months (range, 3.0-90). The follow-up duration in patients with and without cholecystectomy was similar (median, 37 and 40 months, respectively). The follow-up status among the 83 patients by the time of analysis is given in Table 3. The overall incidence of recurrent biliary symptoms was significantly higher among patients with gallbladder in place than among those who had had a cholecystectomy (38.5% vs 1.4%, p < 0.001). Recurrent cholangitis was associated with recurrent bile duct stones in all cases. The three patients with cholangitis and the patient with recurrent bile duct stones underwent successful endoscopic stone clearance. One patient subsequently agreed to LC and had an uneventful operation. Discussion The ERC-ES sequence has proved effective in the management of bile duct stones, and in the laparoscopic era many surgeons--including ourselves [23]--consider preoperative endoscopy followed by laparoscopy to be the best two-step approach to cholecystocholedocholithiasis [9]. This approach requires a preoperative diagnosis of bile duct stones. ERC had been proposed as the investigative method of preoperatively assessing the common bile duct; however, preoperative ERC should not be carried out routinely since, when thus applied, it is not cost-effective [I], most of the endoscopic cholangiograms prove to be normal [18], and the procedure is not without danger [20]. An appropriate balance must be struck to maintain a high yield of positive or thera- peutic ERC, avoid unnecessary ERC, and not miss bile duct stones, while also ensuring acceptably low rates of morbidity and mortality and containing costs. In conclusion, endoscopic assessment of the bile duct should be performed only in patients with a high risk of having bile duct stones. In agreement with other findings [20, 22, 27], our data show that patients with acute cholangitis are those who have a high risk of harboring bile duct stones. The aim of preoperative ERC and ES in patients affected by acute chotangitis due to choledocholithiasis is to quickly decompress the biliary tree to remove the cause of sepsis. In 1977, good results were already being obtained when endoscopic decompression was employed for the management of a particular form of cholangitis, known as "supurative cholangitis" [14], more recently, a randomized trial showed better results after endoscopic biliary drainage followed by definitive treatment than after surgical decompression [13]. An aggressive policy of early endoscopic biliary drainage resulted in a very low mortality rate [22]. On the other hand, delay in ERCP for patients with severe cholangitis resulted in increased mortality and morbidity [4]. Even authors who maintain that the surgical treatment of patients with common bile duct stones is to be preferred to endoscopic management followed by cholecystectomy agree that the endoscopic management of bile duct stones is a better course in patients with severe cholangitis [291. Preoperative ES was performed safely in our hands, and none of the patients in the present study had surgery for their complications. Our early morbidity rate of 4.5% is one of the lowest ever reported in the literature [17, 27]. Endoscopic biliary decompression in acute cholangitis can be obtained not only by ES with clearance of bile duct stones, but also by nasobiliary drainage with or without ES or by stent placement Some authors consider endoscopic nasobiliary drainage or stent placement for acute cholangitis to be safer than ES as an initial step [26], while others believe that elderly patients should undergo endoscopic biliary drainage without sphincterotomy [30]. Like other authors [22], we preferred to carry out ES in all cases because, in addition to the benifits of biliary drainage for control of sepsis, ES allows endoscopic bile duct stone removal and thus the removal of the cause of the disease. Only for patients with unstable hemodynamic status or expected difficulty of stone removal was ES postponed to a later date and

Table 4, Mean operating time, conversion rate, and postoperative outcomes for 1863 standard laparoscopic cholecystectomies for uncomplicated gallstones 979 Parameter Operating time (range) Conversion rate (%) Postoperative outcome Uncomplicated Grade I complications Grade IIa complications Grade lib complications Result 42 min (15-120) 63 (3.4) 95.5% 3.4% 0.5% 0.5% initial drainage obtained by nasobiliary drainage or the insertion of an endoprosthesis to control the sepsis. In accordance with the experience of others [21, 22], we recently decided to use an endoprosthesis because we found it effective for biliary drainage and more convenient than nasobiliary drainage. Although, in contrast to stenting, a nasobiliary catheter is easily flushed to prevent clogging, it can be pulled out by the patient, it causes irritation in the nose or throat, and it is cosmetically less appealing. If the stones are successfully cleared endoscopically, the patient simply proceeds to LC, and the need for surgical exploration of the common bile duct is obviated. In this way, patients suffering from an illness such as acute cholangitis, which can often be serious, can also benefit from the advantages now offered by mini-invasive treatments. Only patients in whom ERCP or endoscopic stone clearance failed were managed by emergency open common bile duct exploration. In our experience, LC performed after ES for acute cholangitis required 57 rain; this time is only 15 min longer than the time required to perform a standard LC (Table 4). Although it is relatively high compared with LC for uncomplicated gallstone disease (Table 4), the conversion rate of 8.6% is acceptable and similar to that reported in similar cases [22]. The main reason for conversion was dense adhesions around the Calot triangle as a result of previous cholangitis. The morbidity observed after interval LC was no different from the incidence observed after standard LC (Table 4); most of the complications in this series were grade 1 [5J--that is, non-life-threatening, with no lasting disability, and which do not extend the hospital stay to more than twice the mean length of time within the same patient group. Although there is little question that severe cholangitis is best managed by endoscopic drainage followed by surgery, it is clear whether this is the best approach for patients with mild cholangitis. For the treatment of cholecysto-choledocholithiasis, a growing number of surgeons advocate the combination of ES and LC with therapeutic flexible biliary endoscopy performed under general anesthesia immediately prior to or immediately after cholecystectomy for a single-session performance of the two techniques [3, 7, 25]. However, none of these reports specifically involved cases of acute cholangitis: thus, it is not possible to evaluate whether this approach is useful in these particular conditions. The results of the multicenter study reported by Cuschieri et al. [6] suggest that single-stage laparoscopic treatment is the best option for the treatment of coexisting gallstones and bile duct stones. Urgent laparoscopic common bile duct exploration for cholangitis has been reported [16], as has elective laparoscopic bile duct exploration in selected cholangitis patients with failed endoscopic stone clearance [22]. Although this technology appears promising, it is not readily available. At the few centers that have expertise and the technology required, a laparoscopic bile duct exploration can be carried out. Our center has had little experience with laparoscopic bile duct exploration because we started to perform it only in selected cases in 1997 [23]; consequently, we have always preferred to perform ES followed by LC in patients affected by acute cholangitis. Even patients with bile duct stones that cannot be extracted by endoscopic means were not selected for laparoscopic exploration of the bile duct because they were considered difficult cases. In fact, they underwent emergency surgery, and some of them had already undergone Billroth II gastrectomy. We believed that open bile duct exploration was safer in these cases. Whether ES followed by LC or laparoscopic common bile duct exploration is the better approach for mild gallstone cholangitis is a subject that needs to be addressed by future studies. Our long-term findings suggest that ES alone is insufficient to treat patients with gallstone cholangitis. Patients managed with ES alone had a significantly higher risk of recurrent biliary symptoms than those who underwent cholecystectomy. On the other hand, mortality due to causes unrelated to cholangitis was also higher in the group of patients managed with ES alone because this group included all high operative risk or elderly patients and those with severe comorbid illnesses. In conclusion, our study confirms that ES followed by LC is a safe and effective approach for the management of gallstone cholangitis; cholecystectomy should be performed in patients with gallstone cholangitis unless the operative risk is extremely high. These high operative risk patients and patients who refuse surgery after ES should be warned about the high risk of recurrent biliary symptoms. References 1, Abboud PA, Malet PF, Berlin JA, Staroscik R, Cabana MD, Clarke JR, Shea JA, Schwartz JS, Williams SV (1996) Predictors of common bile duct stones prior to cholecystectomy: a metaanalysis. Gastrointest Endosc 44:450-457

980 2. Arregui ME, Davis CJ, Arkush AM, Nagan RF (1992) Laparoscopic cholecystectomy combined with endoscopic sphincterotomy and stone extraction or laparoscopic choledochoscopy and electrohydraulic lithotripsy for management of cholelithiasis with choledocholothiasis. Surg Endosc 6:10-15 3. Basso N, Pizzuto G, Surgo D, Materia A, Silecchia G, Fantini A, Fiocca F, Trentino P (1999) Laparoscopic cholecystectomy and intraoperative endoscopic sphincterotomy in the treatment of cholecystocholedocholithiasis. Gastrointest Endoscl 50:532-535 4. Boender J, Nix GA, de Ridder MA, Dees J, Schutte HE, van Buuren HR, van Blankenstein M (1995) Endoscopic sphincterotomy and biliary drainage in patients with cholangitis due to common bile duct stones. Am J Gastroenterol 90:233-238 5. Clavien PA, Sanabria JR, Strasburg SM (1992) Proposed classification of complications of surgery with examples of utility in cholecystectomy. Surgery 111:518-525 6. Cuschieri A, Lezoche E, Morino M, Croce E, Lacy A, Toouli J, Faggioni A, Ribeiro VM, Jakimowiz J, Visa J, et al (1999) EAES multi-center prospective randomized trial comparing two-stage vs single-stage management of patients with gallstone disease and ductal calculi. Surg Endosc 13:952-957 7. De Palma GD, Angrisani L, Lorenzo M, Di Matteo E, Catanzaro C, Persico G, Tesauro BJ (1996) Laparoscopic cholecystectomy, intraoperative ES and CBDS extraction for management of patients with cholecystocholedochotithiasis. Surg Endos I0:646-652 8. Dion YM, Ratelle R, Morin J, Gravel D (1994) Common bite duct exploration. Surg Laparosc Endosc 4:419-424 9. Dorenbusch NJ, Maglinte DDT, Micon LT, Graffis RA, Turner WW Jr (1995) Intravenous cholangiography and the management ofcholedocholithiasis prior to laparoscopic cholecystectomy. Surg Laparosc Endosc 5:188-192 10. Dubois F, Icard P, Berthelot G, Munoz A (1990) Coelioscopic cholecystectomy: preliminary report of 36 cases. Ann Surg 21 l: 60-62 11. Huang SM, Wu CW, Chau GY, Jwo SC, Lui WY, P'eng FK (1996) An alternative approach of choledocholithotomy via laparoscopic choledochotomy. Arch Surg 131:407-411 12. Joyce WP, Keane R, Burke GJ, Daly M, Drumm J, Egan TJ, Delaney PV (1991) Identification of bite duct stones in patients undergoing Iaparoscopic cholecystectomy. Br J Surg 78: 1174-1176 13. Lai ECS, Mok FPT, Tan Esy, Lo CM, Fan ST (1992) Endoscopic biliary drainage for severe acute cholangitis. N Engl J Med 326: 1582-1586 14. Leese T, Neoptolemos JP, Baker AR, Carr-Locke DL (1986) Management of acute cholangitis and the impact of endoscopic sphincterotomy. Br J Surg 73:988-992 15. Leung JWC, Chung SCS, Sung JJY, Banez VP, Li AKC (1989) Urgent endoscopic drainage for acute suppurative cholangitis. Lancet l: 1307-1309 16. Lo CM, Liu CL, Fan ST, Lai ECS, Wong J (1998) Prospective randomized study of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Ann Surg 227:461-467 17. Lorimer JW, Lauzon J, FairfuII-Smith RJ, Yelle JD (1997) Management of choledocholithiasis in the time of laparoscopic cholecystectomy. Am J Surg 174: 68-7t 18. Macintyre IM, Goulborne IA, Gollock JM, Greive DC (1988) Operative cholangiography; a study of observer variation. J R Coil Surg Edinb 33:65-67 19. Millat B, Fingerhut A, Deleuze A, Briandet H, Marrel E, de Seguin Soulier P (1995) Prospective evaluation in 121 consecutive unselected patients undergoing laparoscopic treatment of choledocholithiasis. Br J Surg 82:1266-1269 20, Mills JL, Beck DE, Harford EJ (1985) Routine operative cholangiography. Surg Gynecol Obstet 161:343-345 21. Misra SP, Dwivedi M (1996) Bitiary endoprosthesis as an alternative to endoscopic nasobiliary drr.inage in patients with acute cholangitis. Endoscopy 28:746-749 22. Poon RT, Liu CL, Lo CM, Lam CM, Yuen WK, Yeung C, Fan ST, Wong J (2001) Management of gallstone cholangitis in the era of laparoscopic cholecystectomy. Arch Surg 136:11-16 23. Sarli L, Pietra N, Franz~ A, Colla G, Costi R, Gobbi S, Trivelli M (1999) Routine intravenous cholangiography, selective ERCP, and endoscopic treatment of bile duct stones before laparoscopic cholecystectomy. Gastrointest Endosc 50:200-208 24. Sarli L, Pietra N, Sansebastiano G, Cattaneo G, Costi R, Grattarola M, Peracchia A (1997) Reduced postoperative morbidity after elective laparoscopic cholecystectomy: a stratified matched case-control study. World J Surg 21:872-879 25. Sarli L, Sabadini G, Pietra N, Longinotti E, Carreras F, Peracchia A (1995) Laparoscopic cholecystectomy and endoscopic sphincterotomy under a single anaesthetic: a case report. Surg Laparosc Endosc 5:68-71 26. Sharma BC, Agarwal DK, Baijal SS, Saraswat VA, Choudhuri G, Naik SR (1997) Endoscopic management of acute calculous cholangitis. J Gastroenterol Hepatol 12:874-876 27. Siegel JH, Rodriguez R, Cohen SA, Kasmin FE, Cooperman AM (1994) Endoscopic management of cholangitis: critical review of an alternative technique and report of a large series. Am J Gastroenterol 89:1142-I 146 28. Stoker ME (1995) Common bile duct exploration in the era of laparoscopic surgery. Arch Surg 130i 265-268 29. Suc B, Escat J, Cherqui D, Fourtanier G, Hay JM, Fingerhut A, Millat B (1998) Surgery vs endoscopy as primary treatment in symptomatic patients with suspected common bile duct stones: a multicenter randomized trial. French Association for Surgical Research. Arch Surg 133:702-708 30. Sugiyama M, Atomi Y (1997) Treatment of acute cholangitis due to choledocholithiasis in elderly and younger patients. Arch Surg 132:1129-1133 31. Thompson JE Jr, Tompkins RK, Longmire WP Jr (1982) Factors in management of acute cholangitis. Ann Surg 195:137-145 32. Welch J, Donaldson GA (t976) The urgency of diagnosis and surgical treatment of acute suppurative cholangitis. Am J Surg 131:527-532