【正文】 ously and exploration of a small duct may result in increased morbidity ? Surgeon must be appropriately trained Laparoscopic choledochotomy ? Deflate duodenum with NGT ? Extraport to retract duodenum ? Leave cholangiocatheter in place to prevent deflation of CBD ? Laparoscopic knife for choledochotomy ? Flushing, Fogarty catheter and basket to remove stones ? Once duct confirmed cleared (choledochoscopy) consider: ① T tube。 Williams et al, ANZ J Surg 1994) No single technique will be applicable to the management of all CBD stones Management of CBD stones ? Preoperative ERCP and laparoscopic CBD clearance have equivalent overall outes (Rhodes et al, Lancet, 1998) ERCP LCBDE CBD clearance 75%96% 90% Morbidity 13% 8% Mortality 1% 1% Pancreatitis 3% 1% (Tranter and Thompson, BJS, 2022) ? Patients who have a transcystic approach have a shorter hospital stay Options if laparoscopic transcystic exploration fails ? Ligate cystic duct, plete cholecystectomy and rely on postoperative ERCP ? Perform laparoscopic choledochotomy ? Laparotomy and open CBD exploration Options if laparoscopic choledochotomy fails ? Insert Ttube and extraction of stones after 6 weeks ? Postoperative ERCP ? Conversion to open CBD exploration Total choledocholithiasis 372 Transcystic bile duct clearance286 Failed Transcystic clearance86 Choledochotomy41 ERCP clearance45 Randomized trial in Brisbane (Nathanson et al, Ann Surg, 2022) ←Trial Randomization Randomized trial in Brisbane (Nathanson et al, Ann Surg, 2022) Operative Data (86 Failed Transcystic clearance) ERCP Choledochotomy P No. of stones (mean) Mean diameter of CBD (mm) Operative time: surgery (min) ERCPs / IOCs (min) Total (min) Bile duct closure Not applicable Primary 24 Antegrade stent 10 Ttube 7 Open conversions 1 1 No. having 2 ERCPs 11 0 Randomized trial in Brisbane (Nathanson et al, Ann Surg, 2022) Postoperative Outes (No Mortality) ERCP Choledochotomy P Bile leak 0 6 (2 settled, 3 ERCP, 1 reoperation) Pancreatitis Biochemical 4 3 Clinical (Glascow Score) 1 (2) 1 (4) Severe sepsis 1 1 Retained stone 2 (reoperation) 1 (ERCP) GI bleed 2 (transfusion) 0 Reoperation 3 3 Overall significant morbidity 6 (13%) 7 (17%) NS Hospital stay (mean, days) Recurrent or retained CBD stones ? Recurrent in 10% cases ? More mon in patients with primary duct stones, CBD 16mm and periampullary diverticula ? Retained stones found on Ttube cholangiogram best dealt with by ERCP ? Takes 6 weeks for tract to mature and allow percutaneous radiologically guided stone extraction or choledochoscopy successful in 95% and carries less risk of pancreatitis or haemorrhage Cholelithiasis Suspicion of CBD stones Selective perop cholangiogram No stones LC Routine perop cholangiogram Routine perop ERCP CBD stones CBD stones EST and duct clearance LC LCBDE OCBDE Postop ERCP Failure Failure Success Failure OCBDE LCBDE Failure Algorithm showing the available strategies for management of mon bile duct stones Shojaiefard A, et al. Various techniques for the surgical treatment of mon bile duct stones: a Meta review. Gastroenterology Research and Practice, 2022。 no CBD dilatation。 (177。 normal serum amylase value Biliary pancreatitis Cholelithiasis。 serum amylase value ＞ 3 normal (﹥ 360 U/L)。 poorly localized upper abdominal pain。 normal serum amylase value Resolving choledocholithiasis Cholelithiasis。 elevation in serum liver enzyme values during initial evaluation with decrease in the degree of abnormality during repeat evaluation。 ) 肝功升高 ； 血 AMS正常 膽源性胰腺炎 膽囊結石 ； 持續(xù)性腹痛 ； (177。 234(1): 3340 Group 2 patients Group 1 patients Group 3 patients Group 4 patients Therapeutic ERCP MRCP LC+IOC LC (＋ ) (－ ) Liu TH, et al. Patient evaluation and management with selective use of MRCP and ERCP before LC. Ann Surg 2022。 后 1/3項 ) ； TB升高 ＜ 2倍 (177。 ③ 病人意愿 /經濟情況 。 〔 (a+b)(c+d)(a+c)(b+d )〕 ~ 很好 ~ 一般 ~ 不好 GBS＋ CBDS可能性的評估及存在的問題 陽性預測值 PV＋ =a/(a+b) PV＋ ＝ 〔 pre sen〕247。 〔 d/(b+d)〕 = (1sen)/spe GBS＋ CBDS可能性的評估及存在的問題 ? 連續(xù)計量資料的分界值及其對診斷試驗評價指標的影響： 正常值，截斷值（ cutoff value），根據(jù)不同需要設定的閾值（ threshold）。 ? 以受試者工作特性曲線（ ROC曲線）拐點處為截斷值，即 sen和spe均較高的點。 100％ sen與 100％ PV相對應（排出）； 100％ spe與 100％PV+相對應（納入）；當 sen和 spe不等于 100％時， PV依賴于疾病的患病率（驗前概率） 、且需逐個計算。不受患病率的影響。 indicators：① clinical： history of 膽管炎、黃疸 and胰腺炎 , symptomatic CBDS 、 present 黃疸 and胰腺炎；② serum chemistries： ALT、 AST、 TB、 DB、 ALP、 GGT、 AMS；③CBDS on US、 CBD dilatation on US。 GBS繼發(fā) CBDS的診療策略：尚無一致性的流程？ EBM有望解決此難題？ GBS＋ CBDS可能性的評估及存在的問題 何時繼續(xù)試驗？何時治療？治療方法選擇？ 試驗原則： 應用可能改變處理方案的試驗。 ? Symptomatic CBDS僅保守治療 90％可好轉， 10％死亡。 ()=1/9 AOC的 LR+==18 LR= 驗后比 =驗前比 LR+=1/9 18= 驗后概率 =247。 ()=1/9 LR+==7 LR== 驗后比 =驗前比 LR+=1/9 7=7/9 驗后概率 =7/9247。 ②本單位微創(chuàng)診療的手段： therapeutic ERCP、 MRCP、 IOC、 LC、LC+LCBDE。 ()=15/85 AOC的 LR+==18 驗后比 =驗前比 LR+=15/85 18= 驗后概率 =247。 ()=15/85 LR= = 驗后比 =驗前比 LR=15/85 = 驗后概率 =247。 ()=15/85 LR= = 驗后比 =驗前比 LR=15/85 = 驗后概率 =247。 ()=15/85 LR= =9 驗后比 =驗前比 LR=15/85 9= 驗后概率 =247。（ 15項） CT、 MRCP、 ERCP、 IOC，治療性 ERCP/LCBDE/OCBDE是否取得結石 設計診斷性試驗 ? 各分類指標： sen、 spe、 PV+、 PV、 LR+、 LR 。 ()=15/85 LR= =1 驗后比 =驗前比 LR=15/85 1= 驗后概率 =247。 ()=15/85 LR= =20 驗后比 =驗前比 LR=15/85 = 驗后概率 =247。 ()=15/85 LR= =