EAES ductal stone study

Delivery of a Laparoscopic Bile Duct Exploration Service as a Primary Treatment Modality for Choledocholithiasis within the NHS Healthcare System

INTRODUCTION

The aim of this paper was to report the experience of one-stage LC and LCBDE service within a medium sized acute NHS healthcare trust to demonstrate the feasibility of this treatment modality in terms of safety, quality and effectiveness inside the limitations of the UK's nationalised healthcare system.

METHODS

All patients undergoing LCBDE at our institution from November 2013 - July 2021 were included in the study. Data were collected from a prospectively maintained institutional database and data points corroborated by electronic patient data on hospital systems.

RESULTS

Three hundred and eleven patients underwent LCBDE. Median age was 68 (range 21-95). Most cases were performed as urgent/emergency (n = 206, 66% vs n = 105, 34% elective). Bile duct stones were diagnosed pre-operatively in 23% of cases (n = 73). Intra-operative diagnosis was made using laparoscopic ultrasound (n = 228, 73%), cholangiogram (n = 44, 14%) or combination of both (n = 31, 10%). Laparoscopic completion rate was 94%. 56% were via choledochotomy and 44% trans-cystic. Incidence of bile leak was 4.2% (n = 13) and the incidence of retained stone within 90 days was 3.9%. Median length of stay was 2 days post-operatively (range 0-62). The rate of mortality was 0.66%.

CONCLUSION

The data from our study shows that LC and LCBDE is a safe, effective service that can be successfully delivered in the NHS. With the developing specialisation of benign biliary units, we believe that this approach to choledocholithiasis is reproducible and achievable nationally and should be considered first-line in the management of this condition.

Selective endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy for gallstones

BACKGROUND

To assess the outcome of endoscopic retrograde cholangiography (ERC) before laparoscopic cholecystectomy (LC) for symptomatic gallbladder and suspected duct stones.

METHODS

During 3 years, one or more of four criteria led to ERC: jaundice, choledocus >8 mm, cholestasis, and severe biliary pancreatitis. Endoscopic extraction (ESE) of ductal stones was attempted before LC.

RESULTS

In all, 990 patients were prospectively included. There were no exclusions. There were no deaths. A multivariate logistic regression analysis identified jaundice (P = 0.001), pancreatitis (P = 0.001), and cholestasis (P = 0.001) as statistically significant predictors of ductal stones. Choledocus >8 mm was not a significant predictor (P = 0.12). A total of 155 (16%) patients underwent ERC for suspected stones: 21 of 155 (13%) patients had no stones; and 6 of 134 (4%) patients had stone impaction cleared at open surgery. ERC clearance rate was 95% (128 of 134). LC was performed in 149 of 155 patients after a median interval of 3 days (range 1 to 7). Morbidity rates were 3% (4 of 134), 2% (3 of 149), and nil (0 of 6) after ESE, LC, or open surgery, respectively. Median hospital stay was 11 days. A total of 835 patients underwent LC with a 1.5% complication rate. Laparoscopic fluoro-cholangiography showed < or =3 mm-sized stones in 10 of 835 (1.2%) patients. No stones were reported at a median follow-up of 4 months including 990 patients.

CONCLUSIONS

Ninety-five percent of patients with ductal stones can be successfully and safely managed by ERC prior to LC.