Validierung eines Diagnoseschemas zur präoperativen Detektion von Gallengangskonkrementen bei der laparoskopischen Cholezystektomie
LicenseStandard (Fassung vom 03.05.2003)
Background: A concept of "selective diagnostics" in laparoscopic cholecystectomy (LC) for gallstones was evaluated: Only on patients with suspected common bile duct (CBD) stones a preoperative endoscopic retrograde cholangiopancreatography (ERCP) is performed followed by LC the next day ("therapeutic splitting"). The aim of this retrospective study was to determine the prevalence of choledocholithiasis and to validate a scoring system for the prediction of choledocholithiasis based on alkaline phosphatase, bilirubin, gamma-glutamyltransferase, common bile duct dilatation on preoperative ultrasound, and a history of jaundice. If >= 2 criteria are positive, a preoperative ERCP should be performed before LC. Methods: A total of N = 1,197 consecutive patients were approached and N = 876 (73.1 %) completed questionnaires were returned. Statistical analyses included chi-square tests and stepwise multiple logistic regression analysis. Results: The prevalence of choledocholithiasis was 3.4 %. In 0.9 % choledocholithiasis was missed peroperatively. The overall sensitivity of the scoring system was 57.1 %, while specificity was 88.7 %. Positive predictive value (ppv) was 15.2 %, while negative predictive value (npv) was 98.3 %. Multiple logistic regression analysis identified alkaline phosphatase (p < 0.01) and common bile duct dilatation at preoperative ultrasound (p < 0.001) as independent predictive factors of common bile duct stones. Conclusion: With a prevalence of 3.4 % of CBD stones in patients undergoing laparoscopic cholecystectomy for symptomatic gallstones and a rate of 0.9 % patients with postoperative choledocholithiasis the concept of selective diagnostics of the bile duct appears to be efficient. Although it is difficult to define predictive factors of choledocholithiasis, the above combination of indicators of duct stones in a scoring system to predict choledocholithiasis preoperatively is a simple and safe method using results of routine preoperative investigations.
Subject HeadingsCholezystektomie [GND]
Cholecystectomy, laparoscopic [MeSH]