Laparoscopic Common Bile Duct Exploration in Patients with Complicated Cholecystitis: a Safety and Feasibility Study

Transcholecystic management of extrahepatic duct stones in poor candidates for endoscopic or transhepatic approaches

OBJECTIVES

To investigate transcholecystic management of extrahepatic duct (EHD) stones using balloon ampulloplasty in patients who are poor candidates for endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) and assess its efficacy and safety.

METHODS

Forty-one patients who were unable to undergo ERCP or had failed ERCP with non-dilated intrahepatic ducts (IHD) between February 2019 and October 2020 were retrospectively enrolled. After clinical improvement with percutaneous cholecystostomy (PC), EHD stones were managed through cystic duct passage, guidewire unwinding, sheath insertion, and EHD stone removal using balloon ampulloplasty. If the transcholecystic route failed, a transhepatic approach was used according to the pre-existing cholangiogram obtained via PC. We evaluated the technical success rate and complications of each step.

RESULTS

The technical success rate for the transcholecystic-only approach was 80.5%. The remaining cases were successfully managed with transhepatic conversion. Multiple stone removal sessions were required in 22% of the cases. One patient with combined IHD stones was initially converted to a transhepatic approach without any transcholecystic removal trial. The technical success rates for each step were as follows: cystic duct passage (38/40, 95%), guidewire unwinding (36/38, 94.7%), sheath insertion (36/36, 100%), and stone removal using balloon ampulloplasty (33/36, 91.7%). The overall clinical success was 97.6% (40/41) without major procedure-related complications. Thereafter, cholecystectomy was successfully performed in patients with concomitant gallstones (n = 20). No postprocedural complications occurred during the follow-up (1-70 days).

CONCLUSIONS

Percutaneous EHD stone removal through transcholecystic and transhepatic routes after PC is effective and safe in poor candidates for PTBD or ERCP.

KEY POINTS

• This study shows the safety and efficacy of extrahepatic duct (EHD) stones in patients who are poor candidates for initial percutaneous transhepatic biliary drainage and endoscopic retrograde cholangiopancreatography. • The overall technical success for the transcholecystic-only approach was 80.5% (33/41). Including transhepatic conversions, it was 100% (41/41). Stone removal was successful in one session in 78% (32/41) of the patients and in multiple sessions in 28.1% (9/41) of the patients. • Balloon ampulloplasty with stone expulsion using an occlusion balloon catheter is also a safe and effective method for removing EHD stones.

Surgical Techniques for the Laparoscopic Treatment of Bile Duct Stones in Patients With a History of Upper Abdominal Operations: Retrospective Cohort Study

PURPOSE

Few authors have studied applying the laparoscopic approach in patients with previous upper abdominal operations, but no comparison has been made between laparoscopic and open approaches in patients with previous upper abdominal operations. This article aims to introduce surgical techniques and details in treatment to surgeons specialized in minimally invasive surgery.

MATERIALS AND METHODS

From January 2010 to January 2018, 460 eligible patients were divided into 3 groups and analyzed retrospectively. Group A: patients with a history of upper abdominal operations who underwent laparoscopy (n=124); group B: patients without a history of upper abdominal operations who underwent laparoscopy (n=140); and group C: patients with a history of upper abdominal operations who underwent an open operation (n=196). Group A was the experimental group; groups B and C served as the control groups.

RESULTS

No significant difference was found between groups A and B. Significant differences were found between groups A and C in estimated blood loss (258.3±67.2 vs. 424.7±103.7 mL, P<0.001), postoperative hospitalization (5.7±2.3 vs. 10.2±3.1 d, P<0.001), and postoperative complications (16.1% vs. 42.9%, P=0.013). The final rate of stones clearance was 100% in 3 groups. The total rate of stone recurrence was 7.8%.

CONCLUSIONS

Laparoscopy with certain surgical techniques was feasible, effective, and advantageous for patients with previous upper abdominal operations by experienced surgeons. It is necessary for surgeons to have advanced skills and surgical techniques to achieve a successful laparoscopy.

Percutaneous transcystic balloon dilation for common bile duct stone removal in high-surgical-risk patients with acute cholecystitis and co-existing choledocholithiasis

BACKGROUND

Percutaneous procedures to treat common bile duct (CBD) stones typically require access via intrahepatic bile ducts. This study aimed to describe the outcomes of a percutaneous transcystic approach that expelled the CBD stones into the duodenum after percutaneous transcystic balloon dilation of the ampulla (PTCBDA) for high-risk patients who present with acute cholecystitis and CBD stones.

METHODS

Patients diagnosed with acute cholecystitis and CBD stones who were deemed too high-risk for surgery or general anesthesia and were treated with PTCBDA and CBD stone removal between March 2010 and November 2015 were included for further analysis. Patients underwent emergency percutaneous transhepatic gallbladder drainage under ultrasound. Staged PTCBDA and CBD stone expulsion were performed. Outcomes evaluated included the success rate, causes of failure, and complications.

RESULTS

Eighteen patients met the inclusion criteria. CBD stones were successfully expelled in 16 patients. A second procedure was performed in one patient because of residual stones. The procedure failed in two patients because their stones were large. One patient developed bile peritonitis and underwent percutaneous catheter drainage.

DISCUSSION

Percutaneous transcystic anterograde expulsion of CBD stones may be a feasible and effective method for treating high-risk surgical patients with acute cholecystitis and co-existing CBD stones.

Laparoscopic Common Bile Duct Exploration Versus Open Approach in Cirrhotic Patients with Choledocholithiasis: A Retrospective Study

OBJECTIVE

To evaluate the safety and benefits of laparoscopic common bile duct exploration (LCBDE) compared with open approach (OCBDE) in cirrhotic patients.

MATERIALS AND METHODS

Between January 2009 and December 2012, a total of 113 cirrhotic patients with choledocholithiasis underwent common bile duct (CBD) explorations in our department. There were two groups of patients: A:LCBDE (n = 61) and B:OCBDE (n = 52). Patients' demographic characteristics, surgical data, postoperative outcomes, and long-term results were retrospectively collected and analyzed.

RESULTS

There were no significant differences between the two groups in the demographic characteristics or preoperative status. The transcystic approach was successfully performed in 52 (46.0%) patients (group A:34, group B:20), whereas choledochotomy was successful in 59 (54.0%) patients (group A:27, group B:32). The differences between group A and group B in terms of surgical time (124.9 ± 34.2 minutes versus 132.6 ± 48.6 minutes, P = .323), stone clearance rate (93.4% versus 94.2%, P > .05), short-term complication rate (9.8% versus 13.4%, P = .547), and recurrent stone rate (6.6% versus 5.8%, P > .05) were not statistically significant. However, group A suffered less blood loss [95 (60-200) mL versus 200 (90-450) mL, P < .001] and shorter length of hospital stay (4.7 ± 2.5 days versus 11.3 ± 3.1 days, P < .001) than group B. In the LCBDE group, 4 (6.6%) patients were converted due to heavy inflammation and severe adhesions. No mortality, biliary injury, or stricture occurred during follow-up.

CONCLUSION

LCBDE can be safely performed in patients with Child-Pugh A or B cirrhosis and choledocholithiasis, with considerable efficiency, minimal short-term complications, and acceptable long-term outcomes. LCBDE has the advantages over open CBD exploration of less bleeding and reduced length of hospital stay.

Laparoscopic common bile duct exploration in cirrhotic patients with choledocholithiasis

BACKGROUND

Although laparoscopic common bile duct exploration (LCBDE) has become the standard procedure for most choledocholithiasis patients, the application of this procedure to liver cirrhosis is still in debate. The aim of current study was to evaluate the feasibility and safety of LCBDE in choledocholithiasis patients with compensated liver cirrhosis.

MATERIALS AND METHODS

From January 2006 to December 2012, 346 LCBDE performed in our hospital. According to previous defined liver condition, the patients were divided into group A (liver cirrhosis, n=132) and group B (without cirrhosis, n=214). The perioperative data for the 2 groups were retrospectively reviewed and compared.

RESULTS

LCBDE was successfully completed in 326 patients. Conversion from laparoscopic to open surgery was necessary for 20 patients (5.7%) mainly because of hemorrhage (5, 25%) and severe adhesions (8, 40%); a T-tube was placed in 211 patients (64.7%), and primary closure was done in 115 (35.3%). There was significant difference for groups A and B in term of intraoperative blood loss (85 vs. 35 mL; P<0.01). However, the 2 groups showed no significant differences with respect to mean operation time (2.1 vs. 1.9 h; P=0.07), complication rates (10.6% vs. 8.8%; P=0.6), and mean hospital stay (4.2 vs. 4.0 d; P=0.6), conversion rate (5.3% vs. 6.1%; P=0.77), and retained choledocholithiasis rate (8.3% vs. 7.1%; P=0.65). There was no mortality in both the groups.

CONCLUSION

LCBDE is a feasible, effective, and safe surgical procedure for choledocholithiasis patients with compensated cirrhosis.

Laparoscopic common bile duct exploration in cirrhotic patients with choledocholithiasis

BACKGROUND AND AIMS

Although laparoscopic common bile duct exploration (LCBDE) has become the standard procedure for most choledocholithiasis patients, the application of this procedure to liver cirrhosis is still in debate. The aim of the current study was to evaluate the feasibility and safety of LCBDE in choledocholithiasis patients with compensated liver cirrhosis.

PATIENTS AND METHODS

From January 2006 to December 2012, 346 LCBDEs were performed in our hospital. According to the previously defined liver condition, the patients were divided into group A (liver cirrhosis, n=132) and group B (without cirrhosis, n=214). The perioperative data for the 2 groups were retrospectively reviewed and compared.

RESULTS

LCBDE was successfully completed in 326 patients. Conversion from laparoscopic to open surgery was necessary for 20 patients (5.7%) mainly because of hemorrhage (5, 25%) and severe adhesions (8, 40%). A T-tube was placed in 211 patients (64.7%), and primary closure was performed in 115 (35.3%) patients. There was a significant difference for groups A and B in terms of intraoperative blood loss (85 vs. 35 mL; P<0.01). However, the 2 groups showed no significant differences with respect to the mean operation time (2.1 vs. 1.9 h; P=0.07), complication rates (10.6% vs. 8.8%; P=0.6), mean hospital stay (4.2 vs. 4.0 d; P=0.6), conversion rate (5.3% vs. 6.1%; P=0.77), and retained choledocholithiasis rate (8.3% vs. 7.1%; P=0.65). There was no mortality in both groups.

CONCLUSIONS

LCBDE is a feasible, effective, and safe surgical procedure for choledocholithiasis patients with compensated cirrhosis.

Single-incision laparoscopic common bile duct exploration with conventional instruments: an innovative technique and a comparative study

BACKGROUND

Single-incision laparoscopic surgery developed rapidly in recent years. We introduce an innovative technique: single-incision laparoscopic common bile duct exploration (SILCBDE) with conventional instruments. A retrospective comparison between SILCBDE and standard laparoscopic common bile duct exploration (LCBDE) was analyzed.

METHODS

Thirty-four patients who underwent LCBDE for choledocholithiasis in a period of 17 months were enrolled. Seventeen standard LCBDEs and 17 SILCBDEs were attempted. Simultaneous cholecystectomies were performed.

RESULTS

The stone clearance rate was 94.1% (16 patients) in the standard LCBDE group and 100% in the SILCBDE group. There was no statistical difference in demographic distribution, clinical presentations, and operative results between the two groups, except the SILCBDE group had a higher rate of acute cholecystitis than the standard LCBDE group (76.5 vs. 35.3%; p < 0.05). One procedure (5.9%) in the SILCBDE group was converted to a four-incision transcystic LCBDE. The complication rate was 11.8% (two patients) in the standard LCBDE group and 5.9% (one patient) in the SILCBDE group. The average follow-up period was 4.2 months.

CONCLUSION

SILCBDE is as safe and efficacious as standard LCBDE in experienced hands. Choledochoscope manipulation and bile duct repair are the key skills. Long-term follow-up and further prospective randomized trials are anticipated.