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

Surgical Management of the Horrible Gallbladder

Laparoscopic cholecystectomy is one of the most frequently performed operations by general surgeons, with up to 1 million cholecystectomies performed annually in the United States alone. Despite familiarity, common bile duct injury occurs in no less than 0.2% of cholecystectomies, with significant associated morbidity. Understanding biliary anatomy, surgical techniques, pitfalls, and bailout maneuvers is critical to optimizing outcomes when encountering the horrible gallbladder. This article describes normal and aberrant biliary anatomy, complicated cholelithiasis, ways to recognize cholecystitis, and considerations of surgical approach.

The efficacy and safety of laparoscopic common bile duct exploration with primary duct closure for cholecystolithiasis combined with choledocholithiasis

Cholecystolithiasis combined with choledocholithiasis represents a prevalent disease. At present, regarding the management of the common bile duct (CBD), T-tube drainage (TTD) and primary duct closure (PDC) emerge as two prominent approaches for biliary tract repair after laparoscopic CBD exploration (LCBDE). Here, retrospective analysis was conducted on the clinical records of 157 patients who underwent LCBDE at our hospital between January 2019 and January 2022. All patients were categorized into the PDC group or the TTD group based on the chosen CBD treatment approach. A comparative assessment was made across demographic factors, preoperative conditions, surgical particulars, and postoperative complications. The results showed that PDC is recommended for patients with a limited number of small stones, particularly when the CBD is in the 10-15 mm diameter range.

A Novel Taxonomy of Intraoperative Cholangiograms in Suspected Choledocholithiasis: A Tool for Advancing Laparoscopic Common Bile Duct Exploration Outcomes Research

BACKGROUND

Cholangiography for visualization of the biliary tree during laparoscopic cholecystectomy is an important diagnostic roadmap in the context of suspected choledocholithiasis (CDL). The renewed interest in transcystic laparoscopic common bile duct exploration (LCBDE) necessitates a general description of the range of CDL presentations. Our aim was to establish a novel classification system of intraoperative cholangiograms (IOCs) to advance research efforts in this field.

METHODS

A novel cholangiogram classification system, featuring 8 distinct presentations of choledocholithiasis, was applied to a data set of 80 preintervention IOCs for suspected choledocholithiasis. The classification system is as follows: A (no common bile duct stones, duodenal filling present, and concern for air bubbles), B (no common bile duct stones, no duodenal filling, and concern for sludge), C1 (stone(s) < 2x size of cystic duct with duodenal filling), C2 (stone(s) < 2x size of cystic duct without duodenal filling), D1 (stone(s) ≥ 2x size of cystic duct with duodenal filling), D2 (stone(s) ≥ 2x size of cystic duct without duodenal filling), E1 (congenital anatomical variant and/or common duct stricture), and E2 (surgically altered biliary anatomy).

RESULTS

Cholangiogram review yielded preintervention classifications for 6 of 8 variants (A-E): A (7.5%), B (3.75%), C1 (23.75%), C2 (42.5%), D1 (15%), and D2 (7.5%). Analysis of cystic duct diameter yielded no significant differences among classification groups, indicating no predominant pattern of cystic duct anatomy within a given classification.

DISCUSSION

An IOC classification system for suspected choledocholithiasis is foundational to answering key clinical questions for transcystic laparoscopic common bile duct exploration.

Minimally Invasive Common Bile Duct Stone Management in Gastric Bypass Patients: Laparoscopic Common Bile Duct Exploration with Disposable Bronchoscope

BACKGROUND

Bariatric surgery patients may develop common bile duct stones, and the alterations in their anatomy present challenges in treating this condition. Methods such as laparoscopic bile duct exploration is impractical in many healthcare facilities, due to the absence of a choledochoscope. This study assesses the feasibility of laparoscopic exploration of the common bile duct using a disposable bronchoscope in these individuals.

METHOD

The study involved 32 participants who had undergone gastric bypass surgery. These participants presented with both bile duct stones and bile ducts exceeding 8 mm in diameter, diagnosed through either MRCP or cholangiography conducted during the surgery. Stone extraction was carried out through either choledotomy or transcystic routes using a disposable bronchoscope and endoscopic baskets.

RESULTS

The patients' ages ranged from 27 to 66 years, with a mean bile duct diameter of 11.6 mm (SD 3.1 mm). A 100% stone clearance rate was achieved for all patients. None of the patients required conversion to open surgery. No T-tubes were placed. One patient developed biloma and intra-abdominal abscesses, which were successfully treated with a percutaneous drain over the course of a week. No mortalities were recorded during the course of this study.

CONCLUSION

Our study results demonstrate that laparoscopic bile duct exploration is both feasible and safe in patients who have undergone gastric bypass surgery. The utilization of a disposable bronchoscope emerges as a practical and cost-effective alternative to a choledochoscope in this procedure.

A proposed difficulty grading system for laparoscopic bile duct exploration: benefits to clinical practice, training and research

BACKGROUND

A gap remains between the mounting evidence for single session management of bile duct stones and the adoption of this approach. Laparoscopic bile duct exploration (LBDE) is limited by the scarcity of training opportunities and adequate equipment and by the perception that the technique requires a high skill-set. The aim of this study was to create a new classification of difficulty based on operative characteristics and to stratify postoperative outcomes of easy vs. difficult LBDE irrespective of the surgeon's experience.

METHODS

A cohort of 1335 LBDEs was classified according to the location, number and size of ductal stones, the retrieval technique, utilisation of choledochoscopy and specific biliary pathologies encountered. A combination of features indicated easy (Grades I and II A & B) or difficult (Grades III A and B, IV and V) transcystic or transcholedochal explorations.

RESULTS

78.3% of patients with acute cholecystitis or pancreatitis, 37% with jaundice and 46% with cholangitis had easy explorations. Difficult explorations were more likely to present as emergencies, with obstructive jaundice, previous sphincterotomy and dilated bile ducts on ultrasound scans. 77.7% of easy explorations were transcystic and 62.3% of difficult explorations transductal. Choledochoscopy was utilised in 23.4% of easy vs. 98% of difficult explorations. The use of biliary drains, open conversions, median operative time, biliary-related complications, hospital stay, readmissions, and retained stones increased with the difficulty grade. Grades I and II patients had 2 or more hospital episodes in 26.5% vs. 41.2% for grades III to V. There were 2 deaths in difficulty Grade V and one in Grade IIB.

CONCLUSION

Difficulty grading of LBDE is useful in predicting outcomes and facilitating comparison between studies. It ensures fair structuring and assessment of training and progress of the learning curve. LBDEs were easy in 72% with 77% completed transcystically. This may encourage more units to adopt this approach.

Diagnostic accuracy of updated risk assessment criteria and development of novel computational prediction models for patients with suspected choledocholithiasis

BACKGROUND

There are risks of choledocholithiasis in symptomatic gallstones, and some surgeons have proposed the identification of choledocholithiasis before cholecystectomy. Our goal was to evaluate the diagnostic accuracy of the latest guidelines and create computational prediction models for the accurate prediction of choledocholithiasis.

METHODS

We retrospectively reviewed symptomatic gallstone patients hospitalized with suspected choledocholithiasis. The diagnostic performance of 2019 and 2010 guidelines of the American Society for Gastrointestinal Endoscopy (ASGE) and 2019 guideline of the European Society of Gastrointestinal Endoscopy (ESGE) in different risks. Lastly, we developed novel prediction models based on the preoperative predictors.

RESULTS

A total of 1199 patients were identified and 681 (56.8%) had concurrent choledocholithiasis and were included in the analysis. The specificity of the 2019 ASGE, 2010 ASGE, and 2019 ESGE high-risk criteria was 85.91%, 72.2%, and 88.42%, respectively, and their positive predictive values were 85.5%, 77.4%, and 87.3%, respectively. For Mid-risk patients who followed 2019 ASGE about 61.8% of them did not have CBD stones in our study. On the choice of surgical procedure, laparoscopic cholecystectomy + laparoscopic transcystic common bile duct exploration can be considered the optimal treatment choice for cholecysto-choledocholithiasis instead of Endoscopic Retrograde Cholangio-Pancreatography (ERCP). We build seven machine learning models and an AI diagnosis prediction model (ModelArts). The area under the receiver operating curve of the machine learning models was from 0.77 to 0.81. ModelArts AI model showed predictive accuracy of 0.97, recall of 0.97, precision of 0.971, and F1 score of 0.97, surpassing any other available methods.

CONCLUSION

The 2019 ASGE guideline and 2019 ESGE guideline have demonstrated higher specificity and positive predictive value for high-risk criteria compared to the 2010 ASGE guideline. The excellent diagnostic performance of the new artificial intelligence prediction model may make it a better choice than traditional guidelines for managing patients with suspected choledocholithiasis in future.

A Retrospective Study on the Three-Port Technique of Laparoscopic Common Bile Duct Exploration for the Management of Cholelithiasis and Choledocholithiasis

Background

Laparoscopic cholecystectomy (LC) with laparoscopic common bile duct exploration (LCBDE) is convenient in treating cholelithiasis and choledocholithiasis due to its advantage of accelerated recovery. This retrospective study aimed to summarize the experience of cholelithiasis and choledocholithiasis treatment via three-port approach of LCBDE in Eastern China.

Methods

Patients diagnosed with cholelithiasis and choledocholithiasis between July 2019 and October 2021 were included. Patients who received LC+LCBDE+primary suturing of the common bile duct (CBD) via a three-port approach were assigned to the LCBDE-P group, and those who received LC+LCBDE+T-tube drainage of CBD comprised the LCBDE-T group. The measurement data were compared between the two groups. P-values <0.05 indicated statistical significance.

Results

A total of 88 patients were divided into two groups: LCBDE-P (n=50) and LCBDE-T (n=38). Multiple logistic regression analysis showed that LCBDE-P is associated with a shorter length of stay (OR=0.115, 95% CI: 0.040-0.329, P<0.001) and lower hospitalization costs (OR=0.120, 95% CI: 0.041-0.357, P<0.001). No significant differences between the two groups were detected in the operation time, intraoperative hemorrhage, clearance rate of CBD stones, postoperative liver function, and postoperative complications (P>0.05).

Conclusion

The three-port approach of LCBDE is a safe and feasible strategy for managing cholelithiasis and choledocholithiasis. Compared to LCBDE-T, LCBDE-P reduces the length of hospital stay and medical costs during hospitalization.

Laparoscopic Transcystic Common Bile Duct Exploration: 8-Year Experience at a Single Institution

BACKGROUND

Laparoscopic transcystic common bile duct exploration (LTCBDE) is used to treat cholecystolithiasis and choledocholithiasis. This study aimed to investigate the safety, effectiveness and generalisability of LTCBDE in patients with cholecystolithiasis and choledocholithiasis based on our LTCBDE experience within 8 years.

METHODS

Four hundred patients with cholecystolithiasis and choledocholithiasis (including 62 of cholecystolithiasis and choledocholithiasis with common bile duct no-dilatation) treated with LTCBDE at a single centre from January 2014 to February 2022 were retrospectively evaluated. They were divided into the first 200 and last 200 LTCBDE cases. The disease characteristics, cystic duct incision methods, surgical outcomes and follow-up data were analysed retrospectively. Each patient was followed up for > 3 months.

RESULTS

Four hundred patients underwent LTCBDE, including 188 males and 212 females aged from 15 to 91 years (average age: 56 years). LTCBDE was successful in 377 (94.3%) patients, while treatment was converted to laparoscopic choledocholithotomy with T-tube drainage in 23 (5.8%), owing to intraoperative choledochoscope insertion failure. The CBD diameter (10.89 ± 1.76 vs 9.97 ± 2.39, P < 0.05), cystic duct diameter (4.62 ± 1.03 vs 5.03 ± 1.29, P < 0.05), and operation time (164.60 ± 24.30 vs 135.34 ± 30.00, P < 0.05). Residual stones were found in six (1.5%) patients and removed during the second operation; post-operative bile leakage was found in one (0.3%) patient, who was discharged safely after the second operation.

CONCLUSIONS

Phase I LTCBDE is safe and effective in treating cholecystolithiasis and choledocholithiasis. With continuous technological advances, LTCBDE has been effectively promoted and applied.

Laparoscopic Common Bile Duct Exploration Using a Disposable Bronchoscope

Laparoscopic common bile duct exploration (LCBDE) remains underutilized in the management of common bile duct (CBD) stones. The exact cause of this under-utilization remains unclear; however, identified barriers to LCBDE implementation include lack of training and unavailability of dedicated instruments. LCBDE is an attractive alternative for stone retrieval in patients with Roux-en-Y gastric bypass given the anatomical difficulty in endoscopic retrograde cholangiopaneatography (ERCP). Direct visualization through choledochoscopy is the method of choice for LCBDE. However, dedicated choledoscopes are expensive and not widely available, which may lead surgeons to seek for alternatives at their particular environment. With the COVID-19 pandemic, disposable bronchoscopes have become widely accessible at our institution, raising the possibility of using one for direct vision of the biliary tract. We present the case of a 61-year-old male with past medical history of Roux-en-Y gastric bypass, who presented to the emergency department with a CBD stone. Successful LCBDE was achieved with the aid of a disposable bronchoscope for direct visualization of the biliary tract.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12262-022-03642-7.

Controversias en cirugía: colelitiasis y coledocolitiasis ¿Exploración de vías biliares laparoscópica más colecistectomía laparoscópica (cirugía en un paso) o CPRE y colecistectomía laparoscópica (cirugía en dos pasos)?

Introducción. La colelitiasis tiene una prevalencia del 15 % y el 21 % tendrá coledocolitiasis al momento de la colecistectomía, con 50 % de probabilidad de presentar complicaciones asociadas. Desde el advenimiento de la colecistectomía laparoscópica, el abordaje de la coledocolitiasis ha sido endoscópico, usualmente en un tiempo diferente al vesicular, sin embargo, los avances en laparoscopia han permitido explorar la vía biliar común por la misma vía, pudiendo realizar ambos procedimientos en el mismo tiempo de forma segura. Métodos. Se realizó una búsqueda de la literatura existente con relación al enfoque para el manejo de la colecistocoledocolitasis en un paso comparado con dos pasos. Resultados. Existe evidencia que demuestra mayor efectividad del abordaje en dos pasos, con CPRE y posterior colecistectomía laparoscópica, sobre el abordaje en un paso, especialmente en la tasa de fuga biliar y de cálculos retenidos. El enfoque en un paso con exploración de vías biliares y colecistectomía laparoscópica en el mismo tiempo es seguro, con alta tasa de éxito, baja incidencia de complicaciones, menor estancia hospitalaria y costos. Conclusión. El abordaje laparoscópico en un solo paso es un procedimiento seguro y eficaz para el manejo de la colecisto-coledocolitiasis, con el beneficio de estancia hospitalaria menor, sin embargo, se requieren habilidades técnicas avanzadas en cirugía laparoscópica. En nuestro medio ya existe una infraestructura para el manejo híbrido con CPRE y colecistectomía laparoscópica, pudiéndose realizar ambos en el mismo tiempo, para reducir estancia y costos.

Greater than or equal to 8 mm is a safe diameter of common bile duct for primary duct closure: single-arm meta-analysis and systematic review

Greater than or equal to 8 mm was often used as the safe diameter of primary duct closure (PDC) after laparoscopic common bile duct exploration (LCBDE) in previous studies, but it is impossible to verify the source of this safe diameter, and lack of evidence for the safe diameter of PDC. Hence, this study evaluates the incidence of postoperative complications by single-arm meta-analysis to demonstrate the feasibility of using 8 mm as the safe diameter of PDC, so as to provide reference for clinical selection. Eligible studies were searched by MEDLINE, the Cochrane Library, Embase, and Web of Science from January 1995 to May 2021, investigating eligible literature using PDC after LCBDE for methods of common bile duct closure. The single-arm meta-analysis was analyzed by "meta" package under R 4.0.5, and the pooled incidence of postoperative complications was calculated. Twelve literatures were enrolled in this single-arm meta-analysis including 792 patients. The pooled complications rate including total complications (13.1%, 95% CI 10.1-15.6%), total biliary duct-related complications (9.4%, 95% CI 7.4-11.6%), residual stones (1.3%, 95% CI 0.3-2.7%), bile leakage (5.1%, 95% CI 3.5-6.9%), postoperative pneumonia (2.1%, 95% CI 0.8-3.8%), postoperative acute pancreatitis (1.8%, 95% CI 0.2-4.3%), and stone recurrence (2.6%, 95% CI 1.1-4.4%). The clinical indication of PDC after LCBDE should follow that the diameter of common bile duct ≥ 8 mm as the safe diameter.

Analysis of Laparoscopic Ultrathin Choledochoscope Curative Effect on Common Bile Duct Exploration and Choledocholithotomy in 47 Cases

Objective

The aim of the present study is to summarize the experience of using a 2. 7 mm choledochoscope for laparoscopic cholecystectomy combined with an ultrathin choledochoscope for common bile duct exploration and choledocholithotomy in the treatment of cholecystolithiasis associated with choledocholithiasis after the implementation of strict inclusion and exclusion criteria.

Methods

A retrospective analysis of 47 patients with cholecystolithiasis complicated with choledocholithiasis who were treated in the hepatopancreatobiliary surgery department of the Chinese People's Liberated Army General Hospital between January 2015 and December 2019 was performed in the present study. Clinical data of laparoscopic cholecystectomy combined with ultrathin choledochoscope transcystic duct exploration for common bile duct and choledocholithotomy.

Results

All 47 patients completed the operation successfully. The gallbladder duct was closed using a surgical clamp. Only 2 patients were administered with an abdominal drainage tube. The operation time was 50-160 min, the intraoperative blood loss was 5-50 ml, and the postoperative hospital stay was 2-8 days. No patients had serious complications, such as bile leakage, postoperative bleeding, cholangitis, biliary pancreatitis, and wound infection. Minor complications, such as abdominal pain (Abdominal pain was defined as a patient felt tolerable or unbearable abdominal pain but improved or disappeared with medication) and diarrhea, were present in a few patients; these improved after conservative treatment. There was no recurrence of calculi during the 1-5 years of follow-up, and the patient quality of life was good.

Conclusion

Laparoscopic cholecystectomy combined with ultrathin choledochoscope common bile duct exploration and choledocholithotomy is a safe and effective method after adopting strict inclusion and exclusion criteria. This technology was started in the First Medical Center, Chinese People's Liberation Army General Hospital in September 2009, and it has become extremely mature in the past 5 years.

Management of Common Bile Duct Stones Encountered During Cholecystectomy in Patients With Previous Gastric Bypass

Background: Rapid weight loss following gastric bypass (GBP) predisposes to the development of gallstones, and in those who develop gallstone disease there is a high prevalence of common bile duct stones (CBDS). Furthermore, in these patients, CBDS are difficult to extract due to the altered upper gastrointestinal anatomy following GBP. The aim of the present study was to assess outcome after various management methods applied in the counties of Stockholm and Uppsala, Sweden. Methods: Data from the Swedish Register for Gallstone Surgery and ERCP (GallRiks) and the Swedish Obesity Surgery Register (SoReg) were crossmatched to identify all patients who had undergone gallstone surgery after GBP, where CBDS were found at intraoperative cholangiography, in the Stockholm and Uppsala counties 2009-2013. A retrospective review of patient records was performed for all patients identified. Results: In all, 55 patients were identified. These were managed as follows: expectancy (N = 11); transgastric ERCP (N = 2); laparoscopic choledochotomy (N = 3); open choledochotomy (N = 5); transcystic stone extraction (N = 12); and other approach (N = 13). In nine cases, data on management could not be found. There were nine cases of minor postoperative complication. No retained stones were registered. The operation time was longer for transgastric ERCP (p = 0.002), and the postoperative stay was longer following open and laparoscopic choledochotomy (p < 0.001). There was no statistically significant difference between any of the methods regarding the incidence of postoperative complications (p = 0.098). Discussion: Further development of techniques for managing CBDS discovered in patients undergoing cholecystectomy after previous GBP are needed, as well as more comparative studies with greater statistical power.

Surgical methods of treatment for cholecystolithiasis combined with choledocholithiasis: six years' experience of a single institution

INTRODUCTION

The optimal treatment of choledocholithiasis combined with cholecystolithiasis remains controversial. Common surgical methods vary among endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC), laparoscopic transcystic common bile duct exploration (LTCBDE), laparoscopic transductal common bile duct exploration (LCBDE) with or without T-tube drainage. The purpose of this study is to evaluate the safety and effectiveness of surgical methods and to determine the appropriate procedure for patients with cholecystolithiasis combined with choledocholithiasis.

METHODS

From January 2013 to January 2019, a total of 1555 consecutive patients diagnosed with cholecystolithiasis combined with choledocholithiasis who underwent surgical treatment in Tongji Hospital were retrospectively analyzed. Total 521 patients with intrahepatic bile duct stones underwent LC + LCBDE + T-Tube were excluded from the analysis. At last, 1034 patients who met the inclusion criteria were divided into three groups according to their surgical methods: preoperative ERCP + subsequent LC (ERCP + LC group, n = 275), LC + LCBDE + intraoperative endoscopic nasobiliary drainage (ENBD) + primary duct closure (Tri-scope group, n = 479) and LC + laparoscopic transcystic CBD exploration (LTCBDE group, n = 280). Clinical records, operative findings and postoperative follow-up were collected and analyzed.

RESULTS

There was no mortality in three groups. Common bile duct (CBD) stone clearance rate was 97.5% in ERCP + LC group, 98.7% in Tri-scope group, and 99.3% in LTCBDE group. There were no difference in terms of demographic characteristics, biochemistry findings and presentations, but the Tri-scope group had the biggest diameter and amount of stones and diameter of CBD, the LTCBDE group had the least CBD stones and the biggest diameter of cystic gall duct (CGD). ERCP + LC group have the longest hospital stay (14.16 ± 3.88 days vs 6.92 ± 1.71 days vs 10.74 ± 5.30 days, P < 0.05), also has the longest operative time than others (126.08 ± 42.79 min vs 92.31 ± 10.26 min, 99.09 ± 8.46 min, P < 0.05). Compared to ERCP + LC group, LTCBDE group and Tri-scope group had lower postoperation-leukocyte, shorter surgery duration and hospital stay (P < 0.05). Compared to the Tri-scope group, the LTCBDE group had the shorter hospital stay, extubation time and operation time and less intraoperative bleeding. There were less postoperative complications in LTCBDE group (1.1%) compared to the ERCP + LC group (3.6%) and Tri-scope group (2.2%). Follow-up time was 6 to 72 months. Four patients in ERCP + LC group and 5 in Tri-scope group reported recurrent stones.

CONCLUSION

All the three surgical methods are safe and effective. Tri-scope approach and LTCBDE approach have superiority to preoperative ERCP + LC. LC + LTCBDE shows priority over Tri-scope approach, but should be performed in selected patients. LC + LCBDE + T-Tube can be an alternative management if the other three procedures were failed. The surgeons should choose the most appropriate surgical procedure according to the preoperative examination results and intraoperative situation.

Optimal treatment for concomitant gallbladder stones with common bile duct stones and predictors for recurrence of common bile duct stones

BACKGROUND

The optimal treatment for concomitant gallbladder (GB) stones with common bile duct (CBD) stones and predictors for recurrence of CBD stones are not established.

METHODS

This single-center, retrospective study reviewed 466 patients diagnosed with a first event of concomitant GB stones with CBD stones from January 2010 to December 2018.

RESULTS

92 patients underwent single-stage laparoscopic CBD exploration (LCBDE) and laparoscopic cholecystectomy (LC) (group1), 108 underwent LCBDE + LC after endoscopic stone extraction (ESE) failure (group2), and 266 underwent ESE + LC (group3). Clearance (95.7 vs. 99.1 vs. 97.0%, p = 0.324) and recurrence rates (5.4 vs. 13.0 vs. 7.9%, p = 0.138) did not differ between groups. Group1 had fewer procedures (p < 0.001), lower post-treatment complication rates (7.6 vs. 18.5 vs. 13.9%, p = 0.082), and shorter hospital stay after the first procedure (5.7 vs 13.0 vs 9.8 days, p < 0.001). 40 patients (8.6%) had recurrence of CBD stones at mean follow-up of 17.1 months, of which 29 (72.5%) occurred within 24 months. In multivariate analysis, a CBD diameter > 8 mm, combined type-1 periampullary diverticulum, and age > 70 years were significant predictors of recurrence.

CONCLUSION

Single-stage LCBDE + LC is a safe and effective treatment for concomitant GB stones with CBD stones compared to ESE + LC. LCBDE should be considered in patients with a high risk of ESE failure. Careful follow-up is recommended for patients at high risk of recurrence of CBD stones, especially within 24 months after surgical or endoscopic treatment.

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.

Outcomes of laparoscopic bile duct exploration for choledocholithiasis with small common bile duct

BACKGROUND

Laparoscopic cholecystectomy (LC) combined with laparoscopic common bile duct (CBD) exploration (LCBDE) is one of the main treatments for choledocholithiasis with CBD diameter of larger than 10 mm. However, for patients with small CBD (CBD diameter ≤ 8 mm), endoscopic sphincterotomy remains the preferred treatment at present, but it also has some drawbacks associated with a series of complications, such as pancreatitis, hemorrhage, cholangitis, and duodenal perforation. To date, few studies have been reported that support the feasibility and safety of LCBDE for choledocholithiasis with small CBD.

AIM

To investigate the feasibility and safety of LCBDE for choledocholithiasis with small CBD.

METHODS

A total of 257 patients without acute cholangitis who underwent LC + LCBDE for cholecystolithiasis from January 2013 to December 2018 in one institution were reviewed. The clinical data were retrospectively collected and analyzed. According to whether the diameter of CBD was larger than 8 mm, 257 patients were divided into large CBD group (n = 146) and small CBD group (n = 111). Propensity score matching (1:1) was performed to adjust for clinical differences. The demographics, intraoperative data, short-term outcomes, and long-term follow-up outcomes for the patients were recorded and compared.

RESULTS

In total, 257 patients who underwent successful LC + LCBDE were enrolled in the study, 146 had large CBD and 111 had small CBD. The median follow-up period was 39 (14-86) mo. For small CBD patients, the median CBD diameter was 0.6 cm (0.2-2.0 cm), the mean operating time was 107.2 ± 28.3 min, and the postoperative bile leak rate, rate of residual CBD stones (CBDS), CBDS recurrence rate, and CBD stenosis rate were 5.41% (6/111), 3.60% (4/111), 1.80% (2/111), and 0% (0/111), respectively; the mean postoperative hospital stay was 7.4 ± 3.6 d. For large CBD patients, the median common bile duct diameter was 1.0 cm (0.3-3.0 cm), the mean operating time was 115.7 ± 32.0 min, and the postoperative bile leak rate, rate of residual CBDS, CBDS recurrence rate, and CBD stenosis rate were 5.41% (9/146), 1.37% (2/146), 6.85% (10/146), and 0% (0/146), respectively; the mean postoperative hospital stay was 7.7 ± 2.7 d. After propensity score matching, 184 patients remained, and all preoperative covariates except diameter of CBD stones were balanced. Postoperative bile leak occurred in 11 patients overall (5.98%), and no difference was found between the small CBD group (4.35%, 4/92) and the large CBD group (7.61%, 7/92). The incidence of CBDS recurrence did not differ significantly between the small CBD group (2.17%, 2/92) and the large CBD group (6.52%, 6/92).

CONCLUSION

LC + LCBDE is safe and feasible for choledocholithiasis patients with small CBD and did not increase the postoperative bile leak rate compared with chole-docholithiasis patients with large CBD.

Lessons learnt from the first 200 unselected consecutive cases of laparoscopic exploration of common bile duct stones at a district general hospital

BACKGROUND

The management of choledocholithiasis evolves with diagnostic imaging and therapeutic technology, facilitating a laparoscopic approach. We review our first 200 cases of laparoscopic exploration of the common bile duct, highlighting challenges and lessons learnt.

METHODS

We retrospectively studied the first 200 cases of laparoscopic cholecystectomy with common bile duct exploration between 2006 and 2019. The database contains demographics, clinicopathological characteristics, diagnostic modalities, operative techniques, duration and outcomes.

RESULTS

We compared two approaches: transcystic vs. transcholedochal in our 200 cases. Choledocholithiasis was suspected preoperatively in 163 patients. 21 cases found no stones. Of the remainder, 111/179 cases were completed via the transcystic route and the remaining were completed transcholedochally (68/179); 25% of the transcholedochal cases were converted from a transcystic approach. CBD diameter for transcystic route was 8.2 vs. 11.0 mm for transcholedochal. Total clearance rate was 84%. Retained or recurrent stones were noted in 7 patients. Length of stay was 5.8 days, 3.5 days in the transcystic route vs. 9.4 days after transcholedochal clearance. Eight patients required re-operation for bleeding or bile leak. No mortalities were recorded in this cohort, but 2 cases (1%) developed a subsequent CBD stricture.

CONCLUSION

Concomitant laparoscopic common bile duct clearance with cholecystectomy is feasible, safe and effective in a district general hospital, despite constraints of time and resources. The transcystic route has a lower complication rate and shorter hospital stay, and hence our preference of this route for all cases. Advancements in stone management technology will allow wider adoption of this technique, benefitting more patients.

Five-year follow-up outcomes of laparoscopic choledochoscopy via the cystic duct for choledocholithiasis in patients with gallstones and common bile duct stones

BACKGROUND

There are many treatments for gallstones combined with common bile duct stones. Currently, laparoscopic cholecystectomy plus common bile duct exploration and endoscopic sphincterotomy plus laparoscopic cholecystectomy are often used, but T tube drainage is required for the former, and the latter is controversial due to the destruction of the Oddi sphincter.

AIM

To investigate the clinical effect of laparoscopic choledochoscopy in the treatment of gallstones with common bile duct stones.

METHODS

A total of 125 patients who underwent laparoscopic choledochoscopy and cholecystectomy for gallbladder stones and common bile duct stones were followed for 5 years from January to December 2013. The clinical effects were analyzed.

RESULTS

The operation was successful in 122 cases, with a success rate of 97.6%. The average age of the patients was 58.21 ± 13.01 years old. The mean operation time was 87.95 ± 39.12 min, and mean intraoperative blood loss was 11.27 ± 6.85 mL. All patients underwent balloon dilatation, of whom 33 underwent microctomy at the confluence of the cystic duct and 5 underwent lithotrity via choledochoscopy. The mean time to first postoperative exhaust was 32.48 ± 17.85 h, and mean postoperative hospital stay was 2.03 ± 1.62 d. The rate of complications at short-term follow-up was 5.74%, and there were a total of 7 cases, including 4 cases of postoperative pancreatitis cured by symptomatic treatment with octreotide and ulinastatin, 2 cases of bile leakage cured by ENBD drainage, and 1 case of surgical wound infection cured by re-dresses. The rate of complications at 5-year follow-up was 4.92%, and there were 4 cases of recurrent common bile duct stones, including 1 case with intrahepatic bile duct stones and 2 cases with pancreatitis. Four patients died, of whom two patients had a myocardial infarction, one had a lung infection, and one had a car accident, all of which were not related to the operation.

CONCLUSION

Laparoscopic choledochoscopy for the treatment of gallbladder stones combined with common bile duct stones has both good short- and long-term results, with the advantages of little trauma, rapid recovery, and few complications.

Electrohydraulic lithotripsy and rendezvous nasal endoscopic cholangiography for common bile duct stone: A case report

BACKGROUND

In patients with large stones in the common bile duct (CBD), advanced treatment modalities are generally needed. Here, we present an interesting case of a huge CBD stone treated with electrohydraulic lithotripsy (EHL) by the percutaneous approach and rendezvous endoscopic retrograde cholangiography (ERC) using a nasal endoscope.

CASE SUMMARY

A 91-year-old woman underwent ERC for a symptomatic large CBD stone with a diameter of 50 mm. She was referred to our institution after the failure of lithotomy by ERC, and after undergoing percutaneous transhepatic biliary drainage. We attempted to fragment the stone by transhepatic cholangioscopy using EHL. However, the stones were too large and partly soft clay-like for lithotripsy. Next, we attempted lithotomy with ERC and cholangioscopy by the rendezvous technique using a nasal endoscope and achieved complete lithotomy. No complication was observed at the end of this procedure.

CONCLUSION

Cholangioscopy by rendezvous technique using a nasal endoscope is a feasible and safe endoscopic method for removing huge CBD stones.

Novel Technique for Laparoscopic Common Bile Duct Exploration Using Endovascular Instrumentation

Treatment of choledocholithiasis is sometimes a two-step process involving both surgeons and gastroenterologists. Common bile duct (CBD) exploration can be performed at the same time as cholecystectomy but often requires the use of rigid tools, increasing the risk of CBD damage. Here, we report the case of a 64-year-old man who presented with epigastric pain and a positive Murphy's sign. Ultrasonography revealed cholecystitis with cholelithiasis. Gangrenous cholecystitis was visualized upon surgical exploration, and an intraoperative cholangiogram diagnosed likely choledocholithiasis. Cholecystectomy was completed, and CBD exploration was performed by the manipulation of endovascular equipment using a trans-cystic approach through to the ampulla of Vater, and the patient made a complete recovery without complications. The substantial flexibility, gentleness, and durability of endovascular instruments allow for minimal tension on structures during the removal of gallstones from the CBD, providing safe, definitive treatment for choledocholithiasis during cholecystectomy.