Laparoscopic Transcystic Treatment Biliary Calculi by Laser Lithotripsy

Coledocolitiasis y exploración laparoscópica de la vía biliar. Un estudio de cohorte

Introducción. La coledocolitiasis es la presencia de cálculos en las vías biliares. En la mayoría de los casos se trata mediante la colangio pancreatografía retrógrada endoscópica y menos comúnmente por intervención quirúrgica laparoscópica. El objetivo de este estudio fue describir una cohorte retrospectiva de pacientes sometidos a exploración laparoscópica de la vía biliar. Métodos. Se incluyeron pacientes intervenidos entre los años 2014 y 2018, en dos instituciones de nivel III en Cali, Colombia, referidos para valoración por cirugía hepato-biliar, por dificultad para la extracción de los cálculos por colangio pancreatografia retrograda endoscópica, debido al tamaño, la cantidad, o la dificultad para identificar o canular la papila duodenal. Resultados. De los 100 pacientes incluidos, se encontró que el 72 % fueron mujeres, con rango de edad entre 14 y 92 años. Al 39 % de los pacientes se les extrajo un solo cálculo y al 16 % 10 cálculos. Un 12 % presentaron cálculos gigantes (mayores de 2,5 cm de ancho) y un 44 % presentaron litiasis múltiple. Al 69 % de los pacientes se les realizó colecistectomía. El porcentaje de éxito de limpieza de la vía biliar por laparoscopia fue del 95 %. Discusión. La exploración laparoscópica de la vía biliar es una técnica posible, reproducible, segura y con excelentes resultados para el manejo de la coledocolitiasis.

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.

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.

Rules and technical tricks in extremely difficult laparoscopic cholecystectomies

We remind you of some technical artifices required in order to resolve difficult cases, such as: antegrade laparoscopic cholecystectomy (LC), subtotal laparoscopic cholecystectomy (SLC) and the “stairs” clipping of the cystic duct. Also we acknowledge the closing of the cystic duct. We analyzed the medical records of 15251 laparoscopic cholecystectomies performed during 1994-2015, with emphasis on: surgical technique, conversion rate, hemorrhage, postoperative bile leaking, iatrogenic MBD injuries and mortality. We divided the cases in 5 study groups, group 1 (1994-2004) N= 5138, group 2 (2005-2015) N= 10113, group 3 (fundus first cholecystectomies, N=2348), group 4 (retrograde cholecystectomies, N=12889) and group 5 (subtotal laparoscopic cholecystectomy-SLC, N=14) which we compared regarding the main parameters. We prefer to perform a “step by step” clipping each time the length of the clip does not cover all the circumference of the cystic duct. This artifices, is a simple laparoscopic gesture easy to perform and has the advantage of avoiding a large excessive and risky laparoscopic dissection in the vicinity of the main biliary duct. More seldom we appeal to the suture of the cystic stump using the intra-corporeal knots or a simple stump ligation with an extracorporeal preformed not. We did not encounter any late or early complications following the implementation of this technical laparoscopic artifice. Laborious laparoscopic cholecystectomies performed by a well-trained surgical team ensure the premises of a good performance even while adopting laparoscopic ingenious and difficile gestures that also respect the intra-operatory rules and principals.