Stone clearance and risk factors for failure in laparoscopic transcystic exploration of the common bile duct

Laparoscopic common bile duct exploration is an effective, safe, and less-costly method of treating choledocholithiasis

BACKGROUND

Advancements in laparoscopic techniques led to the adoption of laparoscopic common bile duct exploration (LCBDE) as an alternative to endoscopic retrograde cholangiopancreatography (ERCP) for management of choledocholithiasis (CD). The goal of this study was to describe the initial experience at a safety net hospital with acute care surgeons performing LCBDE for suspected CD. We hypothesized LCBDE would reduce length of stay and hospital costs compared to laparoscopic cholecystectomy (LC) and ERCP performed in the same hospital admission.

METHODS

This was a retrospective case-control study from 2019 to 2023 comparing LCBDE to LC/ERCP among patients diagnosed with CD. Statistical analyses were performed using Mann-Whitney U tests for continuous variables and Chi-square tests for categorical variables. Data reported as median [interquartile range] or research subjects with condition (percentage).

RESULTS

A total of 110 LCBDE were performed, while 121 subjects underwent LC and ERCP. Patients in the LCBDE group were more likely to be female with a total of 87 female subjects (77.6%) compared to 76 male subjects (62.8%) (95% CI 1.14-3.74). Initial WBC was lower in the LCBDE group at 8.4 [6.9-11.8] compared to the LC/ERCP group at 10.9 [7.9-13.5] (p = 0.0013). Remaining demographics and lab values were similar between the two groups. Patients who underwent LCBDE had a significantly shorter length of stay at 2 days [1-3] compared to those in the LC/ERCP group at 4 days [3-6] (p < 0.001). Hospital charges for the LCBDE group were $46,685 [$38,687-$56,703] compared to $60,537 [$47,527-$71,739] for the LC/ERCP group (p < 0.001).

CONCLUSION

LCBDE is associated with significantly lower hospital costs and shorter length of stay with similar post-operative complication and 30-day readmission rates. Our results show that LCBDE is safe and should be considered as a first-line approach in the management of CD.

Surgical strategies for challenging common bile duct stones in the endoscopic era: A comprehensive review of current evidence

While endoscopic retrograde cholangiopancreatography (ERCP) remains the primary treatment modality for common bile duct stones (CBDS) or choledocholithiasis due to advancements in instruments, surgical intervention, known as common bile duct exploration (CBDE), is still necessary in cases of difficult CBDS, failed endoscopic treatment, or altered anatomy. Recent evidence also supports CBDE in patients requesting single-step cholecystectomy and bile duct stone removal with comparable outcomes. This review elucidates relevant clinical anatomy, selection indications, and outcomes to enhance surgical understanding. The selection between trans-cystic (TC) vs trans-choledochal (TD) approaches is described, along with stone removal techniques and ductal closure. Detailed surgical techniques and strategies for both the TC and TD approaches, including instrument selection, is also provided. Additionally, this review comprehensively addresses operation-specific complications such as bile leakage, stricture, and entrapment, and focuses on preventive measures and treatment strategies. This review aims to optimize the management of CBDS through laparoscopic CBDE, with the goal of improving patient outcomes and minimizing risks.

Laparoscopic common bile duct exploration: what factors determine success?

BACKGROUNDS

Laparoscopic common bile duct exploration (LCBDE) has been shown to be effective in managing choledocholithiasis whilst avoiding ERCP-related complications. However, patient and technical factors effects outcome. This study aimed to explore the matters effecting the failure of LCBDE.

METHODS

All patients who underwent a laparoscopic cholecystectomy (LC) between 2007 and 2021 were identified using a prospective database. Data were collected for patients who underwent LCBDE including demographics, pre-operative investigations, intra-operative findings, technique of bile duct clearance and clearance rates, and post-operative outcomes. Predictors of failed LCBDE were identified.

RESULTS

Laparoscopic cholecystectomy was performed in 3648 patients. Of these, 374 underwent LCBDE for suspected choledocholithiasis. Choledochoscopy was most frequently used (58.8%) with a success rate of 84.1%. Small cystic duct diameter (4.7 vs. 3.4 mm, P = 0.002), stone size >6 mm (P = 0.02), stone: cystic duct ratio >1 (P = 0.04), and >3 stones was associated with failed LCBDE by univariate analysis. Small cystic duct diameter (OR: 0.45, 95% CI: 0.26-0.77, P = 0.004) and stone size >6 mm (OR: 0.23, 95% CI: 0.06-0.92), P = 0.04) correlated with failure by multivariate analysis. Failed LCBDE was associated with increased length of stay (6.6 days vs. 3.1 days, P = 0.001), however the rate of serious complications or mortality was unaffected.

CONCLUSION

LCBDE is safe and effective in managing choledocholithiasis. Factors such as cystic duct diameter, size and number of CBD stones, and stone: cystic duct ratio are associated with increased likelihood of inadequate clearance. The presence of these factors can help clinicians in decision making during LCBDE to improve chance of success.

Laparoscopic choledocholithotomy and transductal T-tube insertion with indocyanine green fluorescence imaging and laparoscopic ultrasound: A case report

BACKGROUND

Laparoscopic choledocholithotomy for a large impacted common bile duct (CBD) stone is a challenging procedure because of the technical difficulty and the possibility of postoperative complications, even in this era of minimally invasive surgery. Herein, we present a case of large impacted CBD stones.

CASE SUMMARY

A 71-year-old man showed a distal CBD stone (45 mm × 20 mm) and a middle CBD stone (20 mm × 15 mm) on computed tomography. Endoscopic retrograde cholangiopancreatography failed due to the large size of the impacted stone and the presence of a large duodenal diverticulum. Laparoscopic choledocholithotomy was decided, and we used a near-infrared indocyanine green fluorescence scope to detect and expose the supraduodenal CBD more accurately. Then, the location, size, and shape of the stones were detected using a laparoscopic intraoperative ultrasound. The CBD was opened with a 2-cm-sized vertical incision. After irrigating several times, two CBD stones were removed with the Endo BabcockTM. T-tube insertion was done for postoperative cholangiography and delayed the removal of remnant sludge. The patient had no postoperative complications.

CONCLUSION

Laparoscopic choledocholithotomy by transcholedochal approach and transductal T-tube insertion is a safe and feasible option for large-sized impacted CBD stones.

Factors Influencing Suture Difficulty of T-tube Fixation and Closure in Laparoscopic Common Bile Duct Exploration

BACKGROUND

Suture under the laparoscopy was considered as one of the most difficult and time-consuming tasks in laparoscopic common bile duct (CBD) exploration. Difficult suturing can lead to prolonged suturing time and decreased suturing quality. The aim of this study was to identify preoperative factors associated with the difficulty of T-tube suture following laparoscopic bile duct exploration.

MATERIALS AND METHODS

Retrospective analysis of consecutive patients who experienced successful laparoscopic CBD exploration with T-tube drainage were collected. Perioperative outcomes and short-term and long-term complications were recorded. Associations of the average suture time per stitch with preoperative demographic data and laboratory tests in patients were analyzed.

RESULTS

A total of 106 cases (46 males and 60 females) were included in this study. The average suture time per stitch was between 3 and 7.5 minutes with a median of 4.5 minutes (4, 5). There were no biliary leakage and other T-tube-related complications in all patients during follow-up. Spearman correlation analysis revealed that biliary tract reoperation (r=0.384, P<0.0001) and a higher body mass index (r=0.486, P<0.0001) were positively correlated with the average suture time per stitch, while there was no association between the average suture time per stitch and other preoperative demographic data and preoperative blood parameters, including CBD diameter, age, sex, operative time, preoperative white cell count, alanine transaminase, total bilirubin, and gamma-glutamyl transpeptidase.

CONCLUSIONS

We have identified 2 preoperative variables (biliary tract reoperation and a higher body mass index) that were positively associated with the suture difficulty under laparoscopy. An adequately powered prospective multicentre study is needed to validate our findings.

Choledocholithiasis-a new clinical pathway

The incidence of cholecystectomy in children has increased considerably since the early 1990s. Management of gallbladder disease in children must include an awareness of choledocholithiasis treatment strategies. Both endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct exploration (open or laparoscopic) are accepted management techniques for choledocholithiasis. Laparoscopic cholecystectomy with preoperative or postoperative ERCP is at least a two-procedure process while cholecystectomy with laparoscopic common bile duct exploration (LCBDE) can provide definitive treatment in a single procedure under one anesthetic. Despite this, the trend over the last decade continues towards less LCBDE utilization in favor of ERCP. This trend has resulted in decreased familiarity with LCBDE by adult and pediatric surgeons and their trainees. Access to the necessary tools and education on the technical aspects can allow for successful single-stage treatment of choledocholithiasis by surgeons during laparoscopic cholecystectomy. This may include a pre-defined stepwise algorithm and understanding of all the equipment and resources necessary to perform a LCBDE. Ultimately, increased understanding of the equipment and procedural steps necessary for LCBDE will result in widened adoption of the technique and thus confer advantages to the patient such as decreased length of stay and fewer required anesthetics.

Review of the Endoscopic, Surgical and Radiological Techniques of Treating Choledocholithiasis in Bariatric Roux-en-Y Gastric Bypass Patients and Proposed Management Algorithm

Choledocholithiasis in post-surgical bariatric Roux-en-Y gastric bypass patients presents a significant challenge secondary to altered anatomy. We aim to review the existing management options including either endoscopic, surgical, percutaneous or hybrid means. Current literature suggests reasonably successful cannulation rates for single- or double-balloon ERCP ranging from 50 to 70% and 63-83%, respectively. The hybrid technique of laparoscopic transgastric ERCP has gained popularity with success rates ranging from 90 to 100%. Conventional laparoscopic techniques like transcystic duct and transcholedochal bile duct exploration are still useful options (i.e. high success rates of 81-100% and 83-96%, respectively). The role of percutaneous transhepatic choledochography remains limited although it can help with rapid bile duct decompression. If feasible, treatment pathways should progress from least to more invasive options as required.

Factors That Predict the Success of Laparoscopic Common Bile Duct Exploration for Choledocholithiasis: A 10-Year Study

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) can be performed to treat choledocholithiasis at the time of laparoscopic cholecystectomy. The aim of this study was to identify factors that predict the success of LCBDE.

MATERIALS AND METHODS

A retrospective audit was performed on patients who underwent LCBDE for the management of choledocholithiasis at Northern Health between 2008 and 2018.

RESULTS

A total of 513 patients were identified with an overall success rate of 90.8%. Most LCBDE were done through a transcystic approach with the remainder through a choledochotomy. When comparing patients with a successful operation to those that were unsuccessful, univariate analysis demonstrated significant differences in preoperative white cell count and number of duct stones found. Age and elevated nonbilirubin liver function tests were found to be significant factors associated with the failure of LCBDE on multivariate analysis. The likelihood of a failed operation in those with multiple stones was observed to be almost halved compared with patients with single stone although this did not reach significance [odds ratio (OR): 0.53, 95% confidence interval (CI): 0.28-1.01, P=0.055]. Multivariate analysis indicated that unsuccessful procedures (OR: 10.13, 95% CI: 4.34-23.65, P<0.001) and multiple duct stones (OR: 3.79, 95% CI: 1.66-8.67, P=0.002) were associated with an increased risk of severe complications.

CONCLUSIONS

A single impacted stone may be more difficult to remove, however complications were more likely to be associated with multiple duct stones. With no other clinically relevant predictive factors, and because of the high success of the procedure and the low morbidity, LCBDE remains an option for all patients with choledocholithiasis.

One-stage fluoroscopy-guided laparoscopic transcystic papillary balloon dilation and laparoscopic cholecystectomy in patients with cholecystocholedocholithiasis who previously had undergone gastrectomy for gastric cancer

BACKGROUND

Patients with a history of gastrectomy have a higher incidence of cholecystocholedocholithiasis (CCL) and related morbidities than the general population. However, the management of common bile duct (CBD) stones with endoscopic retrograde cholangiopancreatography is challenging in patients after Roux-en-Y or Billroth II reconstruction because of the altered gastrointestinal anatomy. The aim of the current study was to evaluate the safety and efficacy of one-stage laparoscopic transcystic papillary balloon dilation and laparoscopic cholecystectomy (LTPBD+LC) in patients with previous gastrectomy for gastric cancer.

METHODS

This retrospective cohort study included five patients with CCL who had previously undergone gastrectomy. All five underwent LTPBD+LC between May 2015 and February 2020 at our institution. The primary end-point was complete clearance of the CBD stones.

RESULTS

Of the 311 patients who had undergone gastrectomy for gastric cancer from December 2009 to December 2018 at our institution, six (1.9%) were later diagnosed with CCL. Five of the six patients did not need emergency biliary drainage and underwent conservative therapy and subsequent elective LTPBD+LC. LTPBD+LC was successfully performed in all cases. None of the patients required conversion to open surgery. The rate of complete clearance of the CBD stones was 100%. The mean operative time of the entire procedure was 126 minutes (range, 102-144 minutes), and the mean blood loss was 12.4 mL (range, 1-50 mL). There were no major perioperative complications, and the mean length of postoperative hospital stay was 4.2 days (range, 3-7 days).

CONCLUSION

One-stage LTPBD+LC may be a feasible procedure for patients with CCL who have previously undergone gastrectomy for gastric cancer.

Endoscopic biliary therapy in the era of bariatric surgery

There is an increasing demand and availability of bariatric surgery, with a range of procedures performed, some leading to altered upper gastrointestinal anatomy. The patient population undergoing bariatric surgery is also at increased risk of gallstones and biliary stone disease. Endoscopy (ie, endoscopic retrograde cholangiopancreatography) is the cornerstone of management of biliary stone disease, but may be challenging after bariatric surgery. In this review the endoscopic, surgery assisted, or percutaneous options that may be considered are discussed, based on the details of surgical anatomy and available expertise.

Laparoscopic transcystic common bile duct exploration as treatment for choledocholithiasis after Roux-en-Y gastric bypass

BACKGROUND

Treatment of choledocholithiasis after Roux-en-Y gastric bypass (RYGB) is a therapeutic challenge given the altered anatomy. To overcome this technical difficulty, different modified endoscopic approaches have been described but significant morbidity accompanies these procedures. The aim of the present study is to report our experience with laparoscopic transcystic common bile duct exploration (LTCBDE) as treatment of choledocholithiasis after RYGB.

METHODS

This is a retrospective cohort study of 854 consecutive patients with RYGB at a single institution between January 2007 and December 2019. Our study population focused on patients who developed biliary events after RYGB. Demographic data and perioperative parameters were compared between patients who underwent laparoscopic cholecystectomy (LC) after RYGB with (defined as Group A) and without (defined as Group B) LTCBDE.

RESULTS

Fifty-seven (8.93%) patients developed a biliary event after RYGB that led to LC. Of those, 11 (19.2%) presented choledocholithiasis during intraoperative cholangiogram and were simultaneously treated with LTCBDE (Group A). Choledocholithiasis was unsuspected in the preoperative setting in 7 (63.6%) of the 11 patients. The procedure was successful in 90.9% (n = 10). Comparing Group A and B, no statistically significant differences were found regarding age, gender, length of hospital stay, and morbidity (p > 0.05). Mean operative time of Group A was 113.1 min, adding, on average, 35 min to LC (113.1 min vs 77.9 min, p = 0.004).

CONCLUSIONS

LTCBDE offers an effective approach for common bile duct stones in patients who underwent RYGB. This procedure did not add significant length of hospital stay nor morbidity to laparoscopic cholecystectomy.

Postoperative rendezvous endoscopic retrograde cholangiopancreaticography as an option in the management of choledocholithiasis

BACKGROUND

Rendezvous endoscopic retrograde cholangiopancreaticography (ERCP) is a well-established method for treatment of choledocholithiasis. The primary aim of this study was to determine how different techniques for management of common bile duct stone (CBDS) clearance in patients undergoing cholecystectomy have changed over time at tertiary referral hospitals (TRH) and county/community hospitals (CH). The secondary aim was to see if postoperative rendezvous ERCP is a safe, effective and feasible alternative to intraoperative rendezvous ERCP in the management of CBDS.

METHODS

Data were retrieved from the Swedish registry for cholecystectomy and ERCP (GallRiks) 2006-2016. All cholecystectomies, where CBDS were found at intraoperative cholangiography, and with complete 30-day follow-up (n = 10,386) were identified. Data concerning intraoperative and postoperative complications, readmission and reoperation within 30 days were retrieved for patients where intraoperative ERCP (n = 2290) and preparation for postoperative ERCP were performed (n = 2283).

RESULTS

Intraoperative ERCP increased (7.5% 2006; 43.1% 2016) whereas preparation for postoperative ERCP decreased (21.2% 2006; 17.2% 2016) during 2006-2016. CBDS management differed between TRHs and CHs. Complications were higher in the postoperative rendezvous ERCP group: Odds Ratio [OR] 1.69 (95% confidence interval [CI] 1.16-2.45) for intraoperative complications and OR 1.50 (CI 1.29-1.75) for postoperative complications. Intraoperative bleeding OR 2.46 (CI 1.17-5.16), postoperative bile leakage OR 1.89 (CI 1.23-2.90) and postoperative infection with abscess OR 1.55 (CI 1.05-2.29) were higher in the postoperative group. Neither post-ERCP pancreatitis, postoperative bleeding, cholangitis, percutaneous drainage, antibiotic treatment, ICU stay, readmission/reoperation within 30 days nor 30-day mortality differed between groups.

CONCLUSIONS

Techniques for management of CBDS found at cholecystectomy have changed over time and differ between TRH and CH. Rendezvous ERCP is a safe and effective method. Even though intraoperative rendezvous ERCP is the preferred method, postoperative rendezvous ERCP constitutes an acceptable alternative where ERCP resources are lacking or limited.

The ABCdE score for PREdicting Lithotripsy Assistance during transcystic Bile duct Exploration by Laparoendoscopy (PRE-LABEL)

BACKGROUND

Common bile duct (CBD) stones are reported in ~ 15% of patients who undergo laparoscopic cholecystectomy for symptomatic gallstones. Prior to lithotripsy techniques, transcystic laparoscopic common bile duct exploration (LCBDE) was limited to smaller CBD stones. The addition of lithotripsy to LCBDE increases cost, operative time and staffing requirements. Predicting which patients might require lithotripsy would be useful in operative planning. The primary aim was to investigate clinical variables for predicting lithotripsy assistance during transcystic bile duct exploration by laparoendoscopy (PRE-LABEL). Secondary aims were to develop and validate a predictive scoring tool.

METHODS

A retrospective review of a prospectively collected database of consecutive patients who underwent transcystic LCBDE at a single centre in the UK was performed to investigate clinical variables for PRE-LABEL and develop a scoring tool (ABCdE score: age, bilirubin, CBD diameter, ERCP). Binary logistic regression was used to investigate which independent variables (predictors) were associated with lithotripsy assistance during transcystic LCBDE. The ABCdE score was applied to both UK and Spain patient cohorts to determine its sensitivity, specificity and accuracy.

RESULTS

From 8 pre-operative clinical variables analysed, age ≤ 40 years, bilirubin > two-times upper limit of normal, CBD diameter ≥ 10 mm and ERCP failure of stone extraction were independent predictors of requiring lithotripsy during transcystic LCBDE and formed the ABCdE score. The hazard ratios were 2.87, 3.79, 2.78 and 10.06, respectively. An ABCdE score ≥ 2 resulted in 71% sensitivity, 81% specificity and 79% accuracy in predicting lithotripsy during LCBDE (UK cohort). Validation using a contemporary cohort from Spain yielded similar sensitivity, specificity and accuracy.

CONCLUSIONS

This study represents the only study to date reporting independent predictors of requiring lithotripsy assistance during transcystic LCBDE. ABCdE score ≥ 2 can highlight patients that may require lithotripsy in order to avoid failure of transcystic LCBDE and therefore avoid choledochotomy or post-operative ERCP.

One-stage fluoroscopic-guided laparoscopic transcystic papillary balloon dilation and laparoscopic cholecystectomy for the treatment of choledocholithiasis after Roux-en-Y reconstruction

Patients with a history of gastrectomy have a higher incidence of cholecystocholedocholithiasis and morbidities. In particular, the management of choledocholithiasis with endoscopic retrograde cholangiopancreatography (ERCP) has been challenging in patients after Roux-en-Y or Billroth II reconstruction due to the altered gastrointestinal anatomy. A 92-year-old man presented with high fever. He had undergone laparoscopic distal gastrectomy with Roux-en-Y reconstruction 9 years earlier for gastric cancer. Choledocholithiasis was diagnosed and ERCP was attempted, but cannulation of the papilla of Vater failed. An elective one-stage operation was planned. One-stage fluoroscopic-guided laparoscopic transcystic papillary balloon dilation (LTPBD) and laparoscopic cholecystectomy (LC) were performed. The operation time was 130 min with 3 mL of intraoperative bleeding. The patient was discharged on postoperative day 3 with no complications. We report this case in which one-stage LTPBD and LC was successfully performed for a super-elderly patient with choledocholithiasis after Roux-en-Y reconstruction.

Cardiovascular complications after common bile duct stone extractions

BACKGROUND

Common bile duct stone (CBDS) is a common condition the rate of which increases with age. Decision to treat in particular elderly and frail patients with CBDS is often complex and requires careful assessment of the risk for treatment-related cardiovascular complications. The aim of this study was to compare the rate of postoperative cardiovascular events in CBDS patients treated with the following: ERCP only; cholecystectomy only; cholecystectomy followed by delayed ERCP; cholecystectomy together with ERCP; or ERCP followed by delayed cholecystectomy.

METHODS

The study was based on data from procedures for gallstone disease registered in the Swedish National Quality Register for Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography (GallRiks) 2006-2014. ERCP and cholecystectomy procedures performed for confirmed or suspected CBDS were included. Postoperative events were registered by cross-matching GallRiks with the National Patient Register (NPR). A postoperative cardiovascular event was defined as an ICD-code in the discharge notes indicating myocardial infarct, pulmonary embolism or cerebrovascular disease within 30 days after surgery. In cases where a patient had undergone ERCP and cholecystectomy on separate occasions, the 30-day interval was timed from the first intervention.

RESULTS

A total of 23,591 underwent ERCP or cholecystectomy for CBDS during the study period. A postoperative cardiovascular event was registered in 164 patients and death within 30 days in 225 patients. In univariable analysis, adverse cardiovascular event and death within 30 days were more frequent in patients who underwent primary ERCP (p < 0.05). In multivariable analysis, adjusting for history of cardiovascular disease or events, neither risk for cardiovascular complication nor death within 30 days remained statistically significant in the ERCP group.

CONCLUSIONS

Primary ERCP as well as cholecystectomy may be performed for CBDS with acceptable safety. More studies are required to provide reliable guidelines for the management of CBDS.

The location of bile duct stones may affect intra- and postoperative cholecystectomy outcome: A population-based registry study

BACKGROUND

Treatment for bile duct stones (BDS) depends largely on anatomical circumstances; yet, whether the outcome of cholecystectomies is impacted by the localization of intraoperatively discovered BDS remains largely unknown.

METHODS

A population-based registry study using data from the national Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks). 115,084 cholecystectomies 2006-2016 with the indications gallstone colic or complications were included. The surgical outcome between patients with distal BDS and those with at least one stone above the confluence was compared.

RESULTS

10,704 met the inclusion criteria. Patients with stones above the confluence had 16% longer operation times and significantly higher rates of intraoperative complications (OR 1.47), gut perforation (OR 4.60), and cholangitis (OR 1.96) compared to patients with distal BDS. The highest clearance rate (96%), as reflected by the need for re-ERCP, was seen after intraoperative ERCP, regardless of the localization of the BDS.

CONCLUSIONS

Stones located above the confluence are associated with increased complication risks. These findings stress the importance of carefully considering the optimal methods for BDS removal during surgery.

Management of bile duct stones at cholecystectomy: an Australian single-centre experience over 2 years

BACKGROUND

Bile duct stones with an intact gallbladder can be treated with either bile duct exploration at cholecystectomy or endoscopic retrograde cholangiopancreatography (ERCP) before or after cholecystectomy. The aim of this study was to evaluate the management of bile duct stones at cholecystectomy at our institution. We also aimed to identify risk factors for failure of ductal clearance in our series.

METHODS

A retrospective review of 690 laparoscopic cholecystectomies over a 2-year period was performed. Patients who underwent laparoscopic bile duct exploration formed the study population.

RESULTS

Of 69 patients with suspected bile duct stones at cholecystectomy 67 (97%) patients underwent laparoscopic bile duct exploration upfront. Complete ductal clearance was achieved in 52 (78%) patients. Postoperative complications (10/67, 15%) included postoperative bleeding (2/67, 3%), bile leak (1/67, 1%), and superficial wound infection (1/67, 1%). There was no mortality. The mean operative time was 126 min and the median length of stay was 2 (1-4) days. A wider common bile duct (CBD) (≥ 8 mm) increased the risk of failed ductal clearance (OR 4.50; 95% confidence interval (CI) 1.15-19.23).

CONCLUSION

This study found that laparoscopic bile duct exploration can effectively and safely treat bile duct stones suspected at cholecystectomy.

Holmium laser lithotripsy improves the rate of successful transcystic laparoscopic common bile duct exploration

Purpose

Transcystic laparoscopic common bile duct exploration (LCBDE) seems safer than transductal LCBDE and is associated with fewer biliary complications. It has traditionally been limited to smaller bile duct stones however. This study aimed to assess the ability of laser-assisted bile duct exploration by laparoendoscopy (LABEL) to increase the rate of successful transcystic LCBDE in patients with bile duct stones at the time of laparoscopic cholecystectomy.

Methods

Patients undergoing LCBDE between 2014 and 2018 were retrospectively analysed. Baseline demographic and medical characteristics were recorded, as well as intra-operative findings and post-procedure outcomes. Standard LCBDE via the transcystic route was initially attempted in all patients, and LABEL was only utilised if there was failure to achieve transcystic duct clearance. The transductal route was utilised for failed transcystic extraction.

Results

One hundred and seventy-nine consecutive patients underwent LCBDE; 119 (66.5%) underwent unaided transcystic extraction, 29 (16.2%) required LABEL to achieve transcystic extraction and 31 (17.3%) failed transcystic extraction (despite the use of LABEL in 7 of these cases) and hence required conversion to transductal LCBDE. As such, LABEL could be considered to increase the rate of successful transcystic extraction from 66.5% (119/179) to 82.7% (148/179). Patients requiring LABEL were however more likely to experience major complications (CD III–IV 5.6% vs 0.7%, p = 0.042) although none were specifically attributable to the laser intra-operatively.

Conclusions

LABEL is an effective adjunct to LCBDE that improves the rate of successful transcystic extraction.

Laparoscopic Transcystic Common Bile Duct Exploration in the Emergency Is as Effective and Safe as in Elective Setting

BACKGROUND

Emergent laparoscopic transcystic common bile duct exploration (LTCBDE) has been reported to be on the increase in some institutions, reflecting the growing confidence with the technique. However, no study has focused on the outcomes of LTCBDE in the non-elective setting. The aim of this study is to investigate whether LTCBDE can be performed effectively and safely in the emergency.

METHODS

This is a retrospective study of 500 consecutive patients with choledocholithiasis subjected for LTCBDE at the Hospital Italiano de Buenos Aires from January 2009 to January 2018. Procedures were classified according to the setting as emergent or elective. Demographic data and perioperative parameters were compared between groups.

RESULTS

Throughout the period comprised, 500 patients were admitted for choledocholithiasis and gallstones. A single-step treatment combining LTCBDE and laparoscopic cholecystectomy was attempted: 211 (42.2%) were performed electively and the 289 (57.8%) as an emergency. There was no significant difference in the success rate of LTCBDE (93.9% versus 93.8%, p = 0.975) for the two groups. The operative time was slightly longer in the emergency group (122 ± 63 versus 106 ± 53 min, p = 0.002). Postoperative recovery was slower in the emergency group, as reflected by a higher rate of prolonged postoperative stay (21.1% vs 5.7%, p < .001). The rates of postoperative complications were similar between groups (2.8% vs 5.9%, p = 0.109).

CONCLUSION

Emergent LTCBDE can be performed with equivalent efficacy and morbidity when compared to an elective procedure. Patients undergoing emergent procedures have longer procedures and hospital stays.

Laparoscopic transcystic common bile duct exploration: surgical indications and procedure strategies

BACKGROUND

LTCBDE combined with or without modified techniques is safe and efficacious for the management of gallstones and concomitant, even large, common bile duct (CBD) stones.

METHODS

To describe the surgical indications and procedure strategies of laparoscopic transcystic common bile duct exploration (LTCBDE), a retrospective analysis of 205 patients with concomitant gallstones and CBD stones treated using LTCBDE between June 2008 and June 2015 was performed. Clinical data on disease characteristics, methods for cystic duct incision and CBD stone extraction (with or without laser lithotripsy), and surgical outcomes were collected and reviewed.

RESULTS

CBD stones were successfully cleared in all patients. No patient was converted to choledochotomy or laparotomy. The cystic duct diameter ranged 3-8 mm, and 85 patients with cystic duct diameter ≥ 5 mm. The mean time for CBD stone extraction was 25.3 min, with the operative time ranged from 63 to 170 min. Lithotripsy was used in 74 (36.1%) patients among which 26 patients with cystic duct diameter ≥ 5 mm. Estimated blood loss during surgery was 10-120 ml per patient, and no intra-operative blood transfusions were needed. The mean postoperative hospital stay was 5.1 (range 3-7) days, and postoperative complications developed in seven patients. No bile duct injury, stricture, remnant, recurrent stones, or other adverse events were observed during the mean follow-up of 8 months.

CONCLUSIONS

Based on preoperative MRCP and intra-operative IOC findings about cystic duct diameter, the diameter of CBD, CBD stone size, we summarized and proposed the surgical indications and suitable techniques and strategies during LTCBDE.

Endoscopic Retrograde Cholangiopancreatography (ERCP) with Laparotomic Small-Intestinal Incision Approach for Extraction of a Common Bile Duct (CBD) Stone Following Total Gastrectomy and Roux-en-Y (R-Y) Anastomosis: A Case Report

BACKGROUND Endoscopic retrograde cholangiopancreatography for common bile duct stone in patients who underwent gastrectomy and Roux-en-Y anastomosis is challenging. We report a case in which we performed endoscopic retrograde cholangiopancreatography through a small-intestinal incision approach for a common bile duct stone, which had developed after total gastrectomy and Roux-en-Y anastomosis. CASE REPORT An 86-year-old woman with a history of laparoscopic-assisted total gastrectomy and R-Y anastomosis and incision of the common bile duct and cholecystectomy for common bile duct stone by open surgery 3 years ago presented with abdominal pain. Examination revealed a 10-mm stone in the lower part of common bile duct. We planned a combined endoscopic and open surgical approach. An incision on the Y limb of the Roux-en-Y anastomosis 20 cm from the jejunojejunal anastomosis and insertion of an endoscope through this opening were performed to extract the common bile duct stone. The patient was discharged on postoperative day 22 without complications. CONCLUSIONS For a patient with a common bile duct stone, who underwent gastrectomy and Roux-en-Y anastomosis, with firm adhesions at the porta hepatis, combined endoscopy and open surgery using a small-intestinal incision approach can be effective when small-bowel endoscopes are unavailable or the cannulation to Vater's papilla by them is difficult.

Transcystic versus traditional laparoscopic common bile duct exploration: its advantages and a meta-analysis

BACKGROUND

The best approach for treating common bile duct stones remains a matter of debate. Traditional laparoscopic common bile duct exploration (LCBDE) can cause adverse events such as stenosis of the bile duct. Moreover, with advances in technology and surgical skills, the use of laparoscopic transcystic common bile duct exploration (LTCBDE) is gradually rising.

OBJECTIVES

To compare the safety, feasibility, and short-term clinical benefits of LTCBDE and LCBDE through matched cases.

METHODS

Web of science, Cochrane, PubMed, and CNKI were searched systematically to identify studies published between January 2007 and December 2017 that compared LTCBDE and LCBDE without a restriction of languages. This meta-analysis was performed using Review Manager 5.3.

RESULTS

Twenty-one studies matched the selection criteria, including 1561 cases of LTCBDE and 1500 cases of LCBDE. There was no obvious difference in stone clearance (OR 1.44, 95% CI 0.84-2.47; P = 0.18). However, LTCBDE had a shorter operative time (MD - 17.72, 95% CI - 19.42 to - 16.02; P < 0.00001) and shorter hospital stay (MD - 2.20, 95% CI - 2.32 to - 2.08; P < 0.00001). Besides, the LTCBDE group showed significantly better results for blood loss (MD - 7.61, 95% CI - 8.85 to - 6.37; P < 0.00001) and postoperative complications (OR 0.28, 95% CI 0.19-0.41; P < 0.00001). In addition, LTCBDE was more cost efficient (MD - 2.51, 95% CI - 2.72 to - 2.30; P < 0.00001). Further, we calculated the absolute mean of operative time (LTCBDE:LCBDE = 97.56:117.81 min), hospital stay (LTCBDE:LCBDE = 5.22:8.91 days), hospital expenses (LTCBDE:LCBDE = 8646.121:11848.31 RMB), blood loss (LTCBDE:LCBDE = 29.3:52.0 ml), the rate of CBD stone clearance (LTCBDE:LCBDE = 92.8:95.0%), and postoperative complications (LTCBDE:LCBDE = 6.7:14.6%) in both groups to obtain more convincing results.

CONCLUSIONS

The stone clearance of LTCBDE was equal to that of LCBDE, and LTCBDE demonstrated a shorter operative time, lower blood loss, and other advantages. Thus, the surgical procedure of laparoscopic transcystic choledochotomy is feasible and safe.

Single-stage procedure for the treatment of cholecysto-choledocolithiasis: a surgical procedures review

While laparoscopic cholecystectomy is generally accepted as the treatment of choice for simple gallbladder stones, in cases in which common bile duct stones are also present, clinical and diagnostic elements, along with intraoperative findings, define the optimal means of treatment. All available options must be accessible to the surgical team which must necessarily be multidisciplinary and include a surgeon, an endoscopist, and a radiologist in order to identify the best option for a truly personalized surgery. This review describes the different techniques and approaches used based on distinctive recommendations and factors, according to the specific cases treated and the results achieved.

Safety and efficacy of a novel continuous incision technique for laparoscopic transcystic choledocholithotomy

INTRODUCTION

The purpose of this study was to evaluate the safety and efficacy of a novel continuous incision technique for the cystic duct and the bile duct over the orifice for laparoscopic transcystic choledocholithotomy (LTCL).

METHODS

LTCL was attempted in 103 consecutive patients from January 1998 to March 2015 and was successful in 96 patients. The cystic duct confluence was made by cutting upward from the orifice in 19 patients. The cystic duct was incised downward beyond the orifice to the bile duct in the other 77 patients. Both of these procedures involved LTCL.

RESULTS

LTCL was successful in 96 patients. It failed in seven patients because of large bile duct stones (BDS), left lateral entry of the cystic duct, or the cystic duct's small diameter. The success rates of LTCL were 98% (47/48), 96% (42/44), and 64% (7/11) for patients with BDS <10 mm, 10-20 mm, and ≥20 mm, respectively. The success rate for removing BDS <20 mm was significantly higher than the removal rate for BDS ≥20 mm (P < 0.0001). There was no significant difference between the incidences of complications associated with BDS ≥10 mm and with BDS <10 mm (P = 0.49). In those who underwent successful LTCL, complications occurred in 3 of 23 patients with failed preoperative duodenoscopic sphincterotomy and in 9 of the other 73 patients; the incidence of complications did not significantly differ between these groups (P = 0.93).

CONCLUSION

LTCL is safe and feasible for exploration of the bile duct and removal of BDS <20 mm.

A novel laparoscopic transcystic approach using an ultrathin choledochoscope and holmium laser lithotripsy in the management of cholecystocholedocholithiasis: An appraisal of their safety and efficacy

BACKGROUND

Although laparoscopic transcystic common bile duct exploration (LTCBDE) is the preferred approach for CBD stone clearance, the success rate can vary between 55% and 85%. This study evaluated if ultrathin choledochoscope and holmium laser lithotripsy could improve the success rate of LTCBDE.

METHODS

Records of 126 patients (average age, 46.1 ± 13.8 years) with cholecystocholedocholithiasis treated with laparoscopic cholecystectomy (LC) and LTCBDE were retrospectively reviewed.

RESULTS

LC+LTCBDE was performed successfully in 118 of 126 patients, with a surgical success rate of 93.7%. An ultrathin choledochoscope was used in 75 (63.5%) patients, and holmium lithotripsy was performed in 38 (32.2%) patients. The stone clearance rate was 99.2% (117/118). No significant complications occurred. One hundred (84.7%) patients had excellent and 13 (11%) had good outcomes for an overall success rate (excellent plus good) of 95.7%.

CONCLUSION

Ultrathin choledochoscope and holmium laser lithotripsy can improve the surgical outcomes of LC+LTCBDE with minimal complications.

Laparoscopic Transcystic Common Bile Duct Exploration: Advantages over Laparoscopic Choledochotomy

Purpose

The ideal treatment for choledocholithiasis should be simple, readily available, reliable, minimally invasive and cost-effective for patients. We performed this study to compare the benefits and drawbacks of different laparoscopic approaches (transcystic and choledochotomy) for removal of common bile duct stones.

Methods

A systematic search was implemented for relevant literature using Cochrane, PubMed, Ovid Medline, EMBASE and Wanfang databases. Both the fixed-effects and random-effects models were used to calculate the odds ratio (OR) or the mean difference (MD) with 95% confidence interval (CI) for this study.

Results

The meta-analysis included 18 trials involving 2,782 patients. There were no statistically significant differences between laparoscopic choledochotomy for common bile duct exploration (LCCBDE) (n = 1,222) and laparoscopic transcystic common bile duct exploration (LTCBDE) (n = 1,560) regarding stone clearance (OR 0.73, 95% CI 0.50–1.07; P = 0.11), conversion to other procedures (OR 0.62, 95% CI 0.21–1.79; P = 0.38), total morbidity (OR 1.65, 95% CI 0.92–2.96; P = 0.09), operative time (MD 12.34, 95% CI −0.10–24.78; P = 0.05), and blood loss (MD 1.95, 95% CI −9.56–13.46; P = 0.74). However, the LTCBDE group showed significantly better results for biliary morbidity (OR 4.25, 95% CI 2.30–7.85; P<0.001), hospital stay (MD 2.52, 95% CI 1.29–3.75; P<0.001), and hospital expenses (MD 0.30, 95% CI 0.23–0.37; P<0.001) than the LCCBDE group.

Conclusions

LTCBDE is safer than LCCBDE, and is the ideal treatment for common bile duct stones.

Laparoscopic Transcystic Common Bile Duct Exploration: T-Shaped Incision of Cystic Duct with FREDDY Laser Lithotripsy

OBJECTIVES

Optimal laparoscopic techniques for management of gallstones concomitant with common bile duct (CBD) stones remain under debate. The aim of this study was to evaluate a novel approach to managing gallstones concomitant with large or impacted CBD stones through a modified laparoscopic transcystic CBD exploration (LTCBDE) with frequency-doubled double-pulse neodymium:YAG (FREDDY) laser lithotripsy.

MATERIALS AND METHODS

This retrospective review includes 32 consecutive patients with gallstones concomitant with large or impacted CBD stones who were offered LTCBDE with FREDDY laser lithotripsy between June 2012 and December 2014. Demographic, perioperative, and follow-up data were collected and analyzed retrospectively.

RESULTS

CBD stone clearance was achieved for all patients. There were 13 males and 19 females, among whom there were three patients with a history of abdominal surgery. The diameter of the CBD ranged from 10 to 20 (mean 15.1) mm, and the number of CBD stones ranged from 1 to 5. CBD stones ranged in diameter from 9 to 18 (mean 11.7) mm and 9 patients had stones that were impacted in the CBD. The mean operative time was 123 ± 18 minutes with a range of 72 to 155 minutes. The mean length of postoperative hospital stay was 5.3 (range 4-7) days. All patients recovered normally without morbidity or mortality.

CONCLUSIONS

The modified LTCBDE with a T-shaped incision of the cystic duct and FREDDY laser lithotripsy is a safe and effective means of managing gallstones concomitant with large or impacted CBD stones.

Results of Medium Seventeen Years' Follow-Up after Laparoscopic Choledochotomy for Ductal Stones

Introduction. In a previously published article the authors reported the long-term follow-up results in 138 consecutive patients with gallstones and common bile duct (CBD) stones who underwent laparoscopic transverse choledochotomy (TC) with T-tube biliary drainage and laparoscopic cholecystectomy (LC). Aim of this study is to evaluate the results at up to 23 years of follow-up in the same series. Methods. One hundred twenty-one patients are the object of the present study. Patients were evaluated by clinical visit, blood assay, and abdominal ultrasound. Symptomatic patients underwent cholangio-MRI, followed by endoscopic retrograde cholangiopancreatography (ERCP) as required. Results. Out of 121 patients, 61 elderly patients died from unrelated causes. Fourteen patients were lost to follow-up. In the 46 remaining patients, ductal stone recurrence occurred in one case (2,1%) successfully managed by ERCP with endoscopic sphincterotomy. At a mean follow-up of 17.1 years no other patients showed signs of bile stasis and no patient showed any imaging evidence of CBD stricture at the site of choledochotomy. Conclusions. Laparoscopic transverse choledochotomy with routine T-tube biliary drainage during LC has proven to be safe and effective at up to 23 years of follow-up, with no evidence of CBD stricture when the procedure is performed with a correct technique.

Learning curve and outcome of laparoscopic transcystic common bile duct exploration for choledocholithiasis

BACKGROUND

The best approach for cholecystocholedocholithiasis remains a matter of debate. The aim of this study was to evaluate the technical aspects, learning curve and outcome of laparoscopic transcystic common bile duct exploration (LTCBDE).

METHODS

Patients who underwent laparoscopic cholecystectomy with LTCBDE between January 2007 and December 2012 were identified from an institutional database. Data on preoperative investigations, intraoperative and postoperative findings were retrieved retrospectively from the patients' hospital notes.

RESULTS

There were 399 women (56·4 per cent) and 309 men (43·6 per cent), with a median age of 58 (range 18-87) years. Microincision (incision of the cystic duct at the confluence with the common bile duct (CBD) with extension of only 3-5 mm at the lateral margin of the CBD) and lithotripsy were used in the transcystic exploration in 119 patients, and increased the success rate of LTCBDE from 74·2 to 91·0 per cent. The median duration of operation was 85 (i.q.r. 65-120) min and the median postoperative hospital stay was 2 (1-3) days. Retained common bile duct stones were observed in 13 patients, and postoperative complications developed in 27 patients. The cumulative sum duration of operation learning curve comprised two phases; phase 1 included the first 250 patients and phase 2 the remaining 458 patients. Duration of operation and postoperative hospital stay decreased with increasing volume per surgeon. Recurrence of common bile duct stones was diagnosed in 26 patients during a median follow-up of 4 years.

CONCLUSION

LTCBDE with or without microincision and/or lithotripsy is a safe and effective approach.

Laparoscopic Choledocholithotomy With a Novel Articulating Forceps

PURPOSE

The aim of this study was to assess the safety and effectiveness of laparoscopic common bile duct (CBD) exploration with a novel articulating forceps.

METHODS

A retrospective analysis was carried out of 90 patients who underwent laparoscopic transcholedochal CBD exploration for choledocholithiasis between May 2006 and June 2014. Forty-five patients underwent laparoscopic choledocholithotomy using the routine instruments (group A). Forty-five patients underwent laparoscopic choledocholithotomy using the routine instruments plus the novel articulating forceps (group B). The 2 group populations were similar with regard to demographic data and clinical presentations.

RESULTS

Laparoscopic transcholedochal CBD exploration was successful in all 90 patients. The mean diameter of the CBD was 14.42 mm in group A and 14.73 mm in group B (P > .05). The average number of stones extracted per patient was 4.22 in group A and 4.67 in group B (P > .05). The patients in group A had a significantly longer operative time than the patients in group B (109.38 vs 80.49 minutes; P < .01). The intraoperative blood loss was minimal in both groups, and no major complications were observed in either group. The mean hospitalization stay was 6.60 days in group A and 5.58 days in group B (P < .01).

CONCLUSION

Laparoscopic transcholedochal CBD exploration with the novel articulating forceps is a safe and effective approach to the management of choledocholithiasis that offers a short operating time and short postoperative hospital stay.

Common bile duct exploration in an elderly Asian population

Common bile duct exploration (CBDE) is an accepted treatment for choledocholithiasis. This procedure is not well studied in the elderly population. Here we evaluate the results of CBDE in elderly patients (>70 years) and compare the open (group A) with the laparoscopic group (group B). A retrospective review was performed of elderly patients with proven common bile duct (CBD) stones who underwent CBDE from January 2005 to December 2009. There were 55 patients in group A and 33 patients in group B. Mean age was 77.6 years (70-91 years). Both groups had similar demographics, liver function tests, and stone size-12 mm (range, 5-28 mm). Patients who had empyema (n = 9), acute cholecystitis (n = 15), and those who had had emergency surgery (n = 28) were more likely to be in group A (P < 0.05). The mean length of stay for group A was 11.7 ± 7.3 days; for group B, 5.2 ± 6.3 days; the complication rate was higher in group A (group A, 38.2%; group B, 8.5%; P = 0.072). The overall complication and mortality rate was 29.5% and 3.4%, respectively. CBDE can be performed safely in the elderly with accepted morbidity and mortality. The laparoscopic approach is feasible and safe in elective setting even in the elderly.

Transcystic approach to laparoscopic common bile duct exploration

Background and Objectives:

One-stage laparoscopic management for common bile duct stones in patients with gallbladder stones has gained wide acceptance. We developed a novel technique using a transcystic approach for common bile duct exploration as an alternative to the existing procedures.

Methods:

From April 2010 to June 2012, 9 consecutive patients diagnosed with cholelithiasis and common bile duct stones were enrolled in this study. The main inclusion criteria included no upper abdominal surgical history and the presence of a stone measuring <5 mm. After the gallbladder was dissected free from the liver connections in a retrograde fashion, the fundus of the gallbladder was extracted via the port incision in the right epigastrium. The choledochoscope was inserted into the gallbladder through the small opening in the fundus of the gallbladder extracorporeally and was advanced toward the common bile duct via the cystic duct under the guidance of both laparoscopic imaging and endoscopic imaging. After stones were retrieved under direct choledochoscopic vision, a drainage tube was placed in the subhepatic space.

Results:

Of 9 patients, 7 had successful transcystic common bile duct stone clearance. A narrow cystic duct and the unfavorable anatomy of the junction of the cystic duct and common bile duct resulted in losing access to the common bile duct. No bile leakage, hemobilia, or pancreatitis occurred. Wound infection occurred in 2 patients. Transient epigastric colic pain occurred in 2 patients and was relieved by use of anisodamine. A transient increase in the amylase level was observed in 3 patients. Short-term follow-up did not show any recurrence of common bile duct stones.

Conclusion:

Our novel transcystic approach to laparoscopic common bile duct exploration is feasible and efficient.

The cystohepatic septum: anatomical findings and surgical considerations

INTRODUCTION

The cystohepatic septum (CHS) is located at the interface between the cystic duct and the common hepatic duct. Although its presence may have clinical and surgical implications, the CHS has never been morphologically studied.

AIM

This study aims to determine the prevalence and anatomic characteristics of the cystohepatic septum.

METHODS

Analytical cross-sectional study of 50 cadaveric dissections was performed. The prevalence and anatomic characteristics of the CHS were analyzed. The cystohepatic junction (CHJ) was characterized from two perspectives. The "external CHJ" was defined as the apparent junction of the cystic duct with the common hepatic duct, as viewed from an extraluminal perspective. The "internal CHJ" was defined as the actual junction of the cystic duct lumen with the common hepatic duct lumen, that is, from the intraluminal perspective. In addition to measuring the length of the CHS, the location of the external and internal CHJ along the length of the extrahepatic biliary tract was classified into three zones (proximal, middle, and distal).

RESULTS

A CHS was identified in 21 cases (42%). The average length was 12 mm. In these 21 cases, the external CHJ was located in the middle zone of the extrahepatic biliary tract in 15 (71%) patients, the proximal zone in 3 (14%), and the distal zone in 3 (14%), while the internal CHJ was located downstream in relation to the length of CHS.

CONCLUSIONS

A CHS of variable length was identified in a large percentage of cadaveric dissections. This finding has important implications for surgical interventions on the biliary tract such as choledochotomy for common bile duct exploration, transcystic bile duct exploration, or bilioenteric anastomosis. The presence of a CHS may also represent an anatomic factor predisposing to Mirizzi's syndrome.

Endoscopic Sphincterotomy Using the Rendezvous Technique for Choledocholithiasis during Laparoscopic Cholecystectomy: A Case Report

A 50-year-old male was examined at another hospital for fever, general fatigue and slight abdominal pain. He was treated with antibiotics and observed. However, his symptoms did not lessen, and laboratory tests revealed liver dysfunction, jaundice and an increased inflammatory response. He was then admitted to our hospital and underwent an abdominal computed tomography scan and magnetic resonance cholangiopancreatography (MRCP), which revealed common bile duct (CBD) stones. He was diagnosed with mild acute cholangitis. As the same time, he was admitted to our hospital and an emergency endoscopic retrograde cholangiopancreatography was performed. Vater papilla opening in the third portion of the duodenum and presence of a peripapillary duodenal diverticulum made it difficult to perform cannulation of the CBD. In addition, MRCP revealed that the CBD was extremely narrow (diameter 5 mm). We therefore performed laparoscopic cholecystectomy and endoscopic sphincterotomy using the rendezvous technique for choledocholithiasis simultaneously rather than laparoscopic CBD exploration. After the operation, the patient was discharged with no complications. Although the rendezvous technique has not been very commonly used because several experts in the technique and a large operating room are required, this technique is a very attractive and effective approach for treating choledocholithiasis, for which endoscopic treatment is difficult.

A laparoscopic approach to CBD stones

AIM

: This study aimed to evaluate single-stage surgical (laparoscopic or open) approach to the management of common bile duct (CBD) stones, as treatment of choice.

METHODS

Prospectively collected data to assess outcomes of CBD clearance, morbidity, mortality, and hospital stay, and compared with published data.

RESULTS

Successful clearance of CBD stones was achieved in 96% cases, laparoscopic exploration successful in 83%. Retained stones were found in 4% cases and another 5% developed postoperative complications. Common length of stay in hospital was 2 days, although mean stay was 4 days. Seventy-three percent of cases were elective, 27% were emergencies. Conversion rate to open surgery was 14%, which was mainly in emergency cases. Postoperative mortality was 1.2%, not directly related to the procedure.

CONCLUSIONS

Good outcomes can be achieved, comparing favorably with those of other modalities, when laparoscopic bile duct exploration is chosen as treatment for CBD stones; the best results can be anticipated in elective patients.

Transcystic approach with micro-incision of the cystic duct and its confluence part in laparoscopic common bile duct exploration

BACKGROUND

Laparoscopic transcystic common bile duct exploration has become a safe and ideal treatment of common bile duct stones. This study was designed to explore the clinical value of modified laparoscopic transcystic common bile duct exploration as a first line of treatment for patients with common bile duct stones.

PATIENTS AND METHODS

A retrospective, case-control study of clinically comparable groups of patients who underwent the laparoscopic transcystic approach with micro-incision of the cystic duct and its confluence part in common bile duct exploration (LTM-CBD) (n=110) and laparoscopic common bile duct exploration (LCBD) (n=100) under the care of one surgeon was performed. All clinical data were analyzed retrospectively.

RESULTS

There was no significant difference in terms of operation time between the two groups (P>.05). Postoperative hospital stay and abdominal drainage time were shorter in the LTM-CBD group than in the LCBD group (P<.05). Postoperative bile leakage was seen in 1 case (1 of 110) in the LTM-CBD group and 10 cases (10 of 100) in the LCBD group (P<.05). Twenty patients underwent T-tube drainage in the LCBD group, and primary closure was performed in the other patients; however, all cases in the LTM-CBD group underwent primary closure. The median follow-up was 12 months; 2 patients in the LCBD group who suffered from bile leakage presented with obstructive jaundice due to bile duct stenosis 6 months postoperatively.

CONCLUSIONS

LTM-CBD, which can avoid postoperative T-tube drainage, decrease complications, shorten hospitalization time, and enhance the existing quality, is a minimally invasive, safe, and effective treatment.

Application of electrohydraulic lithotripsy combined with choledochoscopy in laparoscopic transcystic common bile duct exploration

AIM: To evaluate the application value of electrohydraulic lithotripsy combined with choledochoscope in laparoscopic transcystic common bile duct exploration (LTCBDE).

METHODS: Twenty-four patients who were diagnosed with gallbladder stones with common bile duct stones by magnetic resonance cholangiopancreatography underwent LTCBDE. The minimal diameter of stones was 1.6 cm. The hospital stay, operative time and postoperative complications were recorded.

RESULTS: LTCBDE was successful in all the cases. The operative time and hospital stay were 75-210 min and 3-7 d, respectively. One of the patients had residual stones (4.2%) and recovered without treatment.

CONCLUSION: Electrohydraulic lithotripsy combined with choledochoscopy in LTCBDE is an effective and safe way to treat greater stones.

Endoscopic management of bile duct stones: residual bile duct stones after surgery, cholangitis, and "difficult stones"

Endoscopic treatment has become, according to the latest recommendations, the standard treatment for common bile duct stones (CBDS), although in certain situations, surgical clearance of the common duct at the time of laparoscopic cholecystectomy is still considered a possible alternative. The purpose of this article is not to compare endoscopic with surgical treatment of CBDS, but to describe the various techniques of endoscopic treatment, detailing their preferential indications and the various treatment options that must sometimes be considered when faced with "difficult calculi" of the CBD. The different techniques of lithotripsy and the role of biliary drainage with plastic or metallic stents will be detailed as well as papillary balloon dilatation and particularly the technique of sphincterotomy with macrodilatation of the sphincter of Oddi (SMSO), a recently described approach that has changed the strategy for endoscopic management of CBDS. Finally, the overall strategy for endoscopic management of CBDS, with description of different techniques, will be exposed.

Minimally invasive treatment of cholecysto-choledocal lithiasis: The point of view of the surgical endoscopist

The rate of choledocholithiasis in patients with symptomatic cholelithiasis is estimated to be approximately 10%-33%, depending on the patient’s age. Development of Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Surgery and improvement of diagnostic procedures have influenced new approaches to the management of common bile duct stones in association with gallstones. At present available minimally-invasive treatments of cholecysto-choledocal lithiasis include: single-stage laparoscopic treatment, perioperative endoscopic treatment and endoscopic treatment alone. Published data evidence that, associated endoscopic-laparoscopic approach necessitates increased number of procedures per patient while single-stage laparoscopic treatment is associated with a shorter hospital stay. However, current data does not suggest clear superiority of any one approach with regard to success, mortality, morbidity and cost-effectiveness. Considering the variety of therapeutic options available for management, a critical appraisal and decision-making is required. Endoscopic retrograde cholangiopancreatography/EST should be adopted on a selective basis, i.e., in patients with acute obstructive suppurative cholangitis, severe biliary pancreatitis, ampullary stone impaction or severe comorbidity. In a setting where all facilities are available, decision in the selection of the therapeutic option depends on the patients, the number and size of choledocholithiasis stones, the anatomy of the cystic duct and common bile duct, the surgical history of patients and local expertise.

Nationwide study of the treatment of common bile duct stones in Sweden between 1965 and 2009

BACKGROUND

Treatment of common bile duct stones has changed. Open surgery has gradually been replaced by endoscopic and laparoscopic procedures. The aims of this study were to see how common bile duct stones have been treated in Sweden, to establish whether there were differences in morbidity and mortality between these approaches, and to identify factors influencing mortality.

METHODS

All persons undergoing inpatient common bile duct exploration or endoscopic retrograde cholangiopancreatography (ERCP) during 1965-2009 in the Swedish Hospital Discharge Registry, but without a diagnosis of malignancy in the Swedish Cancer Registry, were included. The outcome death was identified by cross-linkage to the Causes of Death Registry. Registry data on possible risk factors for mortality were collected.

RESULTS

A total of 126 885 procedures were performed in 110 119 patients. Open surgery was initially the only available method, but during the 1990s ERCP became predominant. Later, laparoscopic bile duct clearance became an established but uncommon method. A 90-day mortality rate of 0·2 per cent after open surgery, 0·8 per cent after ERCP, 0 per cent after laparoscopic exploration and 0·7 per cent after combined procedures was recorded. After adjustment for confounding, there was no difference in mortality between open surgery and ERCP. Biliary reintervention within 90 days was identified as a risk factor for death, whereas a concomitant diagnosis of pancreatitis reduced the risk.

CONCLUSION

The laparoscopic technique had the lowest mortality and morbidity rates. After adjustment for confounding factors, there was no difference in mortality after open surgery and ERCP. The favourable outcome for laparoscopy may have been due to selection bias, owing to treatment of younger, healthier subjects with less severe disease.

Laparoscopic transcystic exploration for single-stage management of common duct stones and acute cholecystitis

BACKGROUND

Common bile duct (CBD) stones are found in 10% of patients who undergo elective laparoscopic surgery for gallstone disease and in 10-20% of patients who present with acute cholecystitis (AC). For the latter, the role of laparoscopic transcystic exploration of the common duct (LTCE) as part of a single-stage procedure is still unknown.

METHODS

This study, based on a "laparoscopy first" policy, included 201 subjects with cholecystocholedocholithiasis: 104 underwent a scheduled laparoscopic surgery (group A), and 97 where admitted for AC and had urgent laparoscopy (group B). Group B patients were significantly older (68.4 vs. 62.1 years; P = 0.0045), had a higher proportion of women (56% vs. 41%; P = 0.0345), and included more patients in the ASA III-IV class (39% vs. 21%; P = 0.0006). LTCE was performed by using basket-wired catheters. CBD clearance, operating time, conversion rate, morbidity and mortality, postoperative hospital stay, readmission, and residual CBD stones were the main outcome measures.

RESULTS

Clearance of CBD was obtained in 84% of patients of group A and in 80% of patients of group B (P = not significant). Time spent in the operating room was longer for group B (175 vs. 141 min; P = 0.0003). There were no significant differences for postoperative hospital stay (group A 4.9 vs. group B 5.2 days), readmission rate (3.7% vs. 3.7%), and residual CBD stones (2.8% vs. 3.1%). Need to convert and morbidity occurred more frequently in group B (11.7% vs. 4.6% and 28.7% vs. 16.8%, respectively), but differences were not significant. In group A, one patient died from MOFS.

CONCLUSIONS

LTCE has proved to be a simple technique with a high yield of CBD clearance in the acute setting. Courses are comparable to those observed for the same procedure in elective surgery despite the fact that patients with AC are more at risk for drawbacks.

Cost-effective treatment of patients with symptomatic cholelithiasis and possible common bile duct stones

BACKGROUND

Clinicians must choose a treatment strategy for patients with symptomatic cholelithiasis without knowing whether common bile duct (CBD) stones are present. The purpose of this study was to determine the most cost-effective treatment strategy for patients with symptomatic cholelithiasis and possible CBD stones.

STUDY DESIGN

Our decision model included 5 treatment strategies: laparoscopic cholecystectomy (LC) alone followed by expectant management; preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by LC; LC with intraoperative cholangiography (IOC) ± common bile duct exploration (CBDE); LC followed by postoperative ERCP; and LC with IOC ± postoperative ERCP. The rates of successful completion of diagnostic testing and therapeutic intervention, test characteristics (sensitivity and specificity), morbidity, and mortality for all procedures are from current literature. Hospitalization costs and lengths of stay are from the 2006 National Centers for Medicare and Medicaid Services data. The probability of CBD stones was varied from 0% to 100% and the most cost-effective strategy was determined at each probability.

RESULTS

Across the CBD stone probability range of 4% to 100%, LC with IOC ± ERCP was the most cost-effective. If the probability was 0%, LC alone was the most cost-effective. Our model was sensitive to 1 health input: specificity of IOC, and 3 costs: cost of hospitalization for LC with CBDE, cost of hospitalization for LC without CBDE, and cost of LC with IOC.

CONCLUSIONS

The most cost-effective treatment strategy for the majority of patients with symptomatic cholelithiasis is LC with routine IOC. If stones are detected, CBDE should be forgone and the patient referred for ERCP.

Laparoscopic common bile duct exploration in patients with gallstones and choledocholithiasis

Failed ERCP appears to decrease the success rate of a laparoscopic approach for common bile duct exploration.

Objectives:

To compare the effectiveness of laparoscopic common bile duct exploration in patients with failed endoscopic retrograde cholangiopancreatography (ERCP).

Methods:

This is a descriptive, comparative study. Patients with an indication of common bile duct exploration between February 2005 and October 2008 were included. We studied 2 groups: Group A: patients with failed ERCP who underwent LCBDE plus LC. Group B: patients with common bile duct stones managed with the 1-step approach (LCBDE + LC) with no prior ERCP.

Results:

Twenty-five patients were included. Group A: 9 patients, group B: 16 patients. Success rate, operative time, and hospital stay were as follows: group A 66% vs group B 87.5%; group A 187 minutes vs 106 minutes; group A 4.5 days vs 2.3 days; respectively.

Conclusion:

Patients with failed ERCP should be considered as high-complex cases in which the laparoscopic procedure success rate decreases, and the conversion rate increases considerably.

Relationship between periampullary diverticulum and recurrent bile duct stones after endoscopic surgery

AIM: To study the relationship between periampullary diverticulum and recurrent bile duct stones after endoscopic surgery.

METHODS: One hundred and eighty-five patients with periampullary diverticula were divided into two groups: 96 with peripapillary diverticula and 89 with direct opening of biliary duct into the diverticula. Ninety-five patients with non-diverticular disease were used as controls. After 8 years of follow-up, the recurrence rates of bile duct stones were compared among the three groups of patients.

RESULTS: The recurrence rates of bile duct stones at 8 years after endoscopic surgery were 26.32% in patients with periampullary diverticula, 34.83% in patients with direct opening of biliary duct into the diverticula, and 9.47% in controls. Significant differences were noted in the recurrence rates of bile duct stones between controls and the two groups of patients with periampullary diverticula (χ² = 8.78, 17.15, P < 0.05) though there was no statistical difference between the latter two groups (χ² = 1.71, P > 0.05).

CONCLUSION: Periampullary diverticula is closely related to the recurrence of bile duct stones after endoscopic surgery. There is no obvious relationship between the location of diverticula and the recurrence of bile duct stones. Periampullary diverticulum may be an important risk factor for recurrent bile duct stones.

Laparoscopic Common Duct Exploration in 90-Bed Rural Hospital

Laparoscopic common bile duct exploration (LCBDE) is an effective procedure when endoscopic retrograde cholangiopancreatography is not available. From January 2004 until December 2009, 1254 patients presented with biliary tract disease. Laparoscopic cholecystectomy was attempted in 1240 (98%) cases and completed in 1232 (98%) cases. Laparoscopic cholangiograms were performed in 627 (50%) cases. LCBDE was carried out in 33 (2.6%) cases. Of the 33 LCBDEs, 29 (2.3%) were via the cystic duct, four (0.32%) through a choledochotomy; eight (0.64%) of the total laparoscopic cholecystectomies were converted to open cholecystectomies. LCBDE can be done safely in small hospitals and is very useful when endoscopic retrograde cholangiopancreatography is not available.

Laparoscopic transcystic bile duct exploration: the treatment of first choice for common bile duct stones

BACKGROUND

This study was designed to explore the role of transcystic bile duct exploration (TCE) as a first line of treatment for patients with suspected or incidental common bile duct (CBD) stones.

METHODS

A prospective, case-control study of clinically comparable groups of patients who underwent laparoscopic cholecystectomy (LC) alone (n = 1,854) and combined LC/TCE for CBD stones (n = 253) under the care of one surgeon was performed. Other than ultrasonography, no routine preoperative imaging was used; however, we performed routine intraoperative cholangiography on all patients.

RESULTS

There was no difference in age (49 +/- 15 vs. 57 +/- 19, p = 0.7), sex (79% vs. 82% females, p = 0.6), and ASA grade (1.9 +/- 1 vs. 1.8 +/- 1, p = 0.7). A larger proportion of the TCE group presented as an emergency (TCE 45% vs. LC alone 27%, p = 0.03) and more often presented with acute biliary pain compared with LC alone (27% vs. 13%, p = 0.02). Although a majority of the patients in the TCE group had clinical or biochemical risk factors for CBD stones (86%), only 27% had suspected stones on preoperative ultrasound. The incidence of jaundice (6% vs. 20%, p = 0.01) was lower in the LC alone group compared with TCE patients. Previous abdominal surgery was noted in 34% patients who underwent LC alone and 30% in LC/TCE (p = 0.06). Significantly there was no difference in open conversion between the two groups (LC alone 0.5% vs. LC/TCE 0.6%, p = 0.07). Comparison of selected outcome parameters for LC versus TCE showed a postoperative hospital stay of 2 (1-14) vs. 2 (1-17) days (p = 0.07), presentation to resolution 1 (1-11) vs. 1 (1-11) weeks (p = 0.07), and morbidity 1.07% vs. 1.2% (p = 0.07).

CONCLUSIONS

The study advocates single-session laparoscopic cholecystectomy with transcystic CBD exploration as a feasible first choice treatment and the logical next step in the management of patients with CBD stones.

Laparoscopic common bile duct exploration using a rigid nephroscope

Background

Patients with cholelithiasis and choledocholithiasis are increasingly managed with laparoscopic bile duct exploration and cholecystectomy. Large impacted bile duct stones continue to defy laparoscopic extraction. This study explored the feasibility of laparoscopic bile duct clearance using a rigid nephroscope, which is suited to extracting large stones.

Method

This prospective study recruited patients with large bile duct stones and a bile duct wider than 8 mm on ultrasonography. In addition to standard ports for laparoscopic cholecystectomy, a custom-made 9-mm port was introduced in the epigastrium for the rigid nephroscope, which was negotiated into the bile duct through a choledochotomy. Rigid graspers and lithotripters were introduced through the nephroscope to fragment and remove the calculi.

Results

Between December 2005 and September 2008, 18 patients had nephroscope-guided bile duct exploration (mean(s.d.) age 49(13·9) years, bile duct diameter 11·3(2·3) mm). Three patients had solitary stones and 15 had multiple calculi. Most of the stones were removed with graspers, but the lithotripter was required in five patients. The mean(s.d.) hospital stay was 6(2·3) days. Two patients required postoperative endoscopic retrograde cholangiopancreaticography for residual stones.

Conclusion

The rigid nephroscope was useful for laparoscopic bile duct exploration, particularly for large impacted stones.