Porcine Aorto-Renal Artery (PARA) model for laparoscopic transcystic common bile duct exploration: the evolution of a training model to meet new clinical needs

TAVAC: choledochoscopy disposable scopes, and the single-stage vs. two-stage approach to choledocholithiasis

BACKGROUND

Previous studies have been published evaluating the benefits and drawbacks of clearing the common bile duct of stones using a single-stage approach (LCBDE + LC) versus a two-stage approach (ERCP followed by LC). These studies have demonstrated that a single-stage approach offers similar outcomes and morbidities as a two-stage approach, with the added benefit of a lower cost and shorter length of stays. However, it is significant we understand why LCBDE is not commonly performed currently and also the lapse in surgical trainee exposure and competence in LCBDE. This paper aims to address the lapse in surgical trainee exposure to LCBDE, evaluate the scopes currently available to perform LCBDE, and review current data evaluating the risks and benefits of single-stage versus two-stage approaches to.

METHODS

We utilized PubMed to analyze all publications related to the various disposable scopes utilized to perform choledochoscopy. We also discuss the need for disposable scopes and how this new market niche is transforming the choledochoscopy space.

RESULTS

We analyzed the data related to single-stage and two-stage approach to choledocholithiasis. We noted an overall shorter length of stay and also decreased costs in favor of a single-stage approach.

CONCLUSION

A single-stage LCBDE is the most cost-effective treatment option for choledocholithiasis in patients with choledocholithiasis undergoing a cholecystectomy. In addition, single-stage approach is associated with shorter length of stay. Knowledge of the available choledochoscopes and tools available to surgeons to perform choledochoscopy is significant. The evidence does support the use of disposable choledochoscope from a cost and cross-contamination perspective. Additionally, efforts should be made to incorporate LCBDE into the teaching paradigm of surgical training programs.

Learning curve for performing laparoscopic common bile duct exploration in biliary surgery 2.0 era

BACKGROUND

Recent trials and metanalysis have demonstrated the favorable results of laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration (LCBDE) for the treatment of cholecysto-choledocholithiasis. The aim of this study was to evaluate the LC + LCBDE learning curve including transcystic and transductal approaches and its effect on the outcomes.

METHODS

We identified all unselected patients who underwent LC + LCBDE by a single surgeon between May 2017 and July 2021. Pre-, intra-, and postoperative data were analyzed using the cumulative sum (CUSUM) analysis to evaluate the learning curve.

RESULTS

A total of 110 patients were included. Total postoperative complications rate was 12.7%, including bile leakage in six (5.5%) patients. Mean length of hospital stay was 2.7 (1-14) days. No patient had conversion to open surgery. The CUSUM graph divided the learning curve into three distinct phases: (1) Learning (1-38), (2) Competence (39-61) and (3) Proficiency (62-110). There was a significant increase in the transcystic approach rate with each phase (44.7% vs 73.9% vs 98%; P < .001). A significant decrease in the operative time (150.9 vs 117.6 vs 99.9 min; P < .001) and complication rate (21.1% vs 21.7% vs 2%; P = .01) were observed across the three phases.

CONCLUSION

Our data suggest that the learning curve for complete competence in LC + LCBDE is approximately 60 cases, provided that proper training is available. The initial learning phase can be carried out safely and efficiently with acceptable results.

Multi-institutional expert update on the use of laparoscopic bile duct exploration in the management of choledocholithiasis: Lesson learned from 3950 procedures

BACKGROUND

Recently there has been a growing interest in the laparoscopic management of common bile duct stones with gallbladder in situ (LBDE), which is favoring the expansion of this technique. Our study identified the standardization factors of LBDE and its implementation in the single-stage management of choledocholithiasis.

METHODS

A retrospective multi-institutional study among 17 centers with proven experience in LBDE was performed. A cross-sectional survey consisting of a semi-structured pretested questionnaire was distributed covering the main aspects on the use of LBDE in the management of choledocholithiasis.

RESULTS

A total of 3950 LBDEs were analyzed. The most frequent indication was jaundice (58.8%). LBDEs were performed after failed ERCP in 15.2%. The most common approach used was the transcystic (63.11%). The overall series failure rate of LBDE was 4% and the median rate for each center was 6% (IQR, 4.5-12.5). Median operative time ranged between 60-120 min (70.6%). Overall morbidity rate was 14.6%, with a postoperative bile leak and complications ≥3a rate of 4.5% and 2.5%, respectively. The operative time decreased with experience (P = .03) and length of hospital stay was longer in the presence of a biliary leak (P = .04). Current training of LBDE was defined as poor or very poor by 82.4%.

CONCLUSION

Based on this multicenter survey, LBDE is a safe and effective approach when performed by experienced teams. The generalization of LBDE will be based on developing training programs.

Novel advances in surgery for Gallstone Disease

PURPOSE OF REVIEW

Examine recent advances in the treatment of patients with complex gallstone disease.

RECENT FINDINGS

Laparoscopic common bile duct exploration (LCBDE) has been shown to be an effective and safe treatment for choledocholithiasis, resulting in decreased hospital length of stay and costs when compared with ERCP plus laparoscopic cholecystectomy (LC). Novel simulator-based curricula have recently been developed to address the educational gap that has resulted in an underutilization of LCBDE. Patients with cholecystitis who are too ill to safely undergo LC have traditionally been treated with percutaneous cholecystostomy (PC). Endoscopic ultrasound (EUS) guided gallbladder drainage is a novel definitive treatment for such patients and has been shown to result in decreased complications and hospital readmissions compared to PC. The management of symptomatic gallstone disease during pregnancy has evolved over the last several decades. While it is now well established that laparoscopic procedures under general anesthesia are safe throughout a pregnancy, recent studies have suggested that laparoscopic cholecystectomy during the third trimester specifically may result in higher rates of preterm labor when compared with non-operative management. Finally, indocyanine green (ICG) fluorescence cholangiography is a novel imaging modality that has been used during laparoscopic cholecystectomy and may offer better visualization of biliary anatomy during dissection when compared with traditional intraoperative cholangiography. A number of recent technological, procedural, educational, and research innovations have enhanced and expanded treatment options for patients with complex gallstone disease.