Utilization of Laparoscopic Choledochoscopy During Bile Duct Exploration and Evaluation of the Wiper Blade Maneuver for Transcystic Intrahepatic Access

Percutaneous transhepatic choledochoscopy in the management of hepatolithiasis: a narrative review

Background and Objective

From the 1980s and continuing into the 21st century, percutaneous transhepatic choledoscopy (PTCS) has been increasingly used in the clinical management of cholelithiasis. However, when compared to conventional minimally invasive techniques such as endoscopic retrograde cholangiopancreatography (ERCP), PTCS is characterized by greater invasiveness and a higher rate of complications. As a result, PTCS is frequently used as a supplementary treatment option. Nevertheless, it plays a unique and indispensable role in addressing hepatolithiasis. In this study, to facilitate safer clinical applications and gain a deeper understanding of PTCS-related complications, we conducted a comprehensive examination of these complications.

Methods

Research studies related to PTCS were reviewed in PubMed, Web of Science, and China National Knowledge Infrastructure (CNKI) (year range, 1952-2024). There was no restriction on language. The occurrence and management of complications at various steps of PTCS were examined and compared with those of first-line minimally invasive treatments via a tabular method. Additionally, we evaluated the feasibility of using PTCS in the context of intrahepatic bile duct stones.

Key Content and Findings

Information on the types, incidence, and treatment of complications of PTCS was extracted in this review. A total of 5,923 results were retrieved, of which 41 were excluded. The reason for exclusion was that the article was a meeting comment. The findings indicate that PTCS plays an important role in the treatment of biliary tract diseases.

Conclusions

Although PTCS is frequently used as an adjunctive therapeutic approach, its distinct utility in treating intrahepatic bile duct stones remains difficult to replace. Thus, a deeper understanding of PTCS-related complications, coupled with ongoing advancements in instrumentation, could significantly enhance the efficiency of minimally invasive gallstone management.

Results during the learning curve in the laparoscopic common bile duct exploration for choledocolithiasis

OBJECTIVES

To analyze the results obtained in terms of efficacy and safety during the learning curve of a surgical team in the technique of laparoscopic common bile duct exploration with cholecystectomy (LCBDE+LC) using choledochoscopy for the treatment of patients with cholelithiasis and choledocolithiasis or common bile duct stones (CBDS) (CDL).

METHODS

Single-center prospective analysis of patients treated with LCBDE+LC during the first 4 years of implementation of the technique. A descriptive and comparative analysis was carried out between groups according to the transcystic (TCi) or transcolecocal (TCo) approach, and also evolutionary by periods. The effectiveness of the technique was evaluated using the variable success rate and safety through the analysis of the overall complication rate and the bile leak rate as the most frequent adverse effect.

RESULTS

A total of 78 patients were analyzed. The most frequent approach was TCo (62%). The overall success rate was 92%. The TCi group had a shorter operating time, a lower overall complications rate and a shorter hospital stay. The TCo approach was related to a higher rate of clinically relevant bile leak (8%). Complex cases increased significantly during the learning curve without effect on the overall results.

CONCLUSIONS

LCBDE+LC is an effective and safe technique during the learning curve. Its results are comparable to those published by more experienced groups and do not present significant differences related to the evolution during learning period.

Feasibility and safety of choledochotomy primary closure in laparoscopic common bile duct exploration without biliary drainage: a retrospective study

Common bile duct (CBD) exploration and T-tube drainage are the main surgical methods for the removal of bile duct stones (BDSs), which can now be completed by laparoscopy. However, the feasibility and safety of primary closure of the CBD (PCCBD) in laparoscopic CBD exploration (LCBDE) without biliary drainage are still uncertain. From January 1, 2021, to June 30, 2022, patients who were diagnosed with BDSs and underwent LCBDE and primary closure of the CBD without biliary drainage in our hospital were included. The clinical and prognostic data of the patients were retrospectively analyzed to determine the feasibility and safety of PCCBD in LCBDE without biliary drainage. Forty-nine patients successfully underwent PCCBD in LCBDE without biliary drainage. The operation time was 158.8 ± 50.3 (90-315,150) minutes, the bile duct suture time was 17.6 ± 4.46 (10-26, 18) minutes, the intraoperative blood loss volume was 70.4 ± 52.6 (5-200, 80) ml, the hospitalization cost was 28,141.2 ± 7011.3 (15,005.45-52,959.34, 26,815.14) CNY Yuan, the hospitalization time was 13.22 ± 5.16 (8-32, 12) days, and the postoperative hospitalization time was 7.31 ± 1.94 (3-15, 7) days. There were 3 cases of postoperative bile leakage (3/49, 6.12%), all of them healed by nonsurgical treatment. During the follow-up of 17.2 ± 11.01 (10-26, 17) months, no residual BDSs, biliary stricture or other complications classified as Clavien-Dindo grade I or higher occurred. For some selected patients who meet certain criteria, PCCBD in LCBDE without biliary drainage is feasible and safe and is more conducive to the rapid postoperative recovery of patients.

Diagnostic performance of laparoscopic transcystic common bile duct exploration for the detection of choledocholithiasis in patients with negative MRCP

There is little research to evaluate laparoscopic transcystic common bile duct (CBD) exploration (LTCBDE) as a diagnostic test to identify choledocholithiasis undergoing laparoscopic cholecystectomy (LC). This study aimed to assess the technical success and safety of LTCBDE in patients with suspected choledocholithiasis but negative magnetic resonance cholangiopancreatography (MRCP) undergoing LC. We did an ambispective cohort study in patients with gallstones and suspected CBD stones but negative MRCP undergoing LC. The primary outcomes were the rate of complications in the hospital. Between January 2010 and December 2018, 620 patients (median age, 58 years; 58.4% female) were eligible for the study. The success rate of LTCBDE was 91.8% and CBD stones were observed in 53.3% with a stone clearance rate of 99.3%. The overall postoperative complication rate was 0.65% and no death was recorded in the total cohort. Notably, the morbidity in LTCBDE is 0.53%. Retained CBD stones were diagnosed in 2 patients and managed by ERCP successfully. In the LTCBDE cohort, the median duration of operation was 78 (60-100) min and the median postoperative hospital stay was 1 (1-2) days. Overall, at a mean follow-up of 4.1 (2.3-6.1) years, recurrent CBD stones occurred in 1.1% and all-cause mortality in 0.6%. LTCBDE should be considered the favored choice in the diagnostic algorithm for patients with suspected choledocholithiasis but negative MRCP undergoing LC.

Effects of laparoscopic and choledochoscopic gallbladder-preserving cholecystolithotomy on levels of operation indicators, gallbladder function, and cholecystokinin type-A receptor in patients with gallstones

Introduction

Gallstones are a common digestive system disease.

Aim

To assess the effects of laparoscopic and choledochoscopic gallbladder-preserving cholecystolithotomy on the levels of operation indicators, gallbladder function, and cholecystokinin type-A receptor (CCKAR) in patients with gallstones.

Material and methods

The medical records of 100 patients with gallstones receiving operation from July 2019 to August 2022 were collected for retrospective analysis. They were divided into a laparoscopic group (n = 48) and a laparoscopic + choledochoscopic group (n = 52). The laparoscopic group received totally laparoscopic cholecystolithotomy, while the laparoscopic + choledochoscopic group underwent laparoscopic and choledochoscopic cholecystolithotomy. Their perioperative indicators, gallbladder function, stress indicators (cortisol (Cor), norepinephrine (NE), and C-reactive protein (CRP)), serum biochemical indicators (liver receptor homologue 1 (LRH-1), CCKAR, and vasoactive intestinal peptide (VIP)), and complications were compared.

Results

The fasting gallbladder volume and gallbladder contraction rate increased, and the minimum residual volume and gallbladder wall thickness decreased in the laparoscopic + choledochoscopic group in comparison with those of the laparoscopic group 6 months after operation (p < 0.05). The levels of serum Cor, NE, CRP, and CCKAR were elevated, whereas the levels of serum LRH-1 and VIP were lowered in both groups 3 d after operation compared with those before operation (p < 0.05). The levels of serum Cor, NE, CRP, LRH-1, and VIP were lower, and the level of serum CCKAR was higher in the laparoscopic + choledochoscopic group than those in the laparoscopic group 3 d after operation (p < 0.05).

Conclusions

Both laparoscopic gallbladder-preserving cholecystolithotomy and laparoscopic and choledochoscopic cholecystolithotomy are effective for treating gallstones. However, the latter combination method is superior in enhancing postoperative gallbladder function, decreasing the recurrence risk, regulating the expressions of LRH-1, CCKAR, and VIP, and promoting the postoperative recovery of gastrointestinal function.

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.