A stratified intraoperative surgical strategy is mandatory during laparoscopic common bile duct exploration for common bile duct stones. Lessons and limits from an initial experience of 92 patients

Comparative study of three common bile duct closure techniques after choledocholithotomy: safety and efficacy

PURPOSE

T-tube drainage, primary closure, and biliary stenting are the common bile duct closure methods. There is great debate on the optimal duct closure technique after common bile duct exploration. This study aimed to assess the safety and efficacy of the three commonest common bile duct closure methods after common bile duct exploration for common bile duct stone for future generalization.

METHODS

In this analysis, 211 patients with common bile duct stone underwent common bile duct exploration from January 2016 to December 2020. The patients were divided according to common bile duct closure techniques into three groups, including the T-tube drainage group (63 patients), primary duct closure group (61 patients), and antegrade biliary stenting group (87 patients).

RESULTS

The incidence of overall biliary complications and bile leak were statistically significantly lower in the biliary stenting group than in the other two groups. Also, hospital stays, drain carried time, return to normal activity, re-intervention, and re-admission rates were statistically significantly lower in the biliary stenting group than in the other two groups. There were no statistically significant differences regarding operative and choledochotomy time, retained and recurrent stone, stricture, biliary peritonitis, cholangitis, and the cost among the three groups.

CONCLUSIONS

We state that the biliary stenting procedure should be the preferred first option for common bile duct closure after common bile duct exploration when compared with T-tube drainage and primary duct closure.

TRIAL REGISTRATION

ClinicalTrials.gov PRS (Approval No. NCT04264299).

Dilation of the cystic duct confluence in laparoscopic common bile duct exploration and stone extraction in patients with secondary choledocholithiasis

Background

Many options exist for the management of cholelithiasis and secondary choledocholithiasis. Among them, laparoscopic common bile duct exploration (LCBDE) with choledocotomy followed by laparoscopic cholecystectomy has gained popularity. However, efforts should be made to ensure minimally invasive or noninvasive management of the common bile duct (CBD). The purpose of this study was to explore the clinical experience of non-invasive surgical modality, i.e., laparoscopic transcystic dilation of the cystic duct confluence in CBD exploration (LTD-CBDE), including feasibility, safety, adverse events, and incidence.

Methods

In this retrospective analysis, 68 patients were offered the LTD-CBDE technique from December 2015 to April 2018 based on patient’s own intention. During the surgery, the cystic duct confluence was dilated with separation forceps and/or a columnar dilation balloon. Subsequently, CBD exploration and stone extraction were performed with a choledochoscope. The entrance of the CBD was covered with a cystic duct stump wall and was subjected to primary closure at the end of surgery.

Results

Forty-nine females and 19 males with cholelithiasis and secondary choledocholithiasis were included. The mean age was 53 years old (18 to 72 year). Of these patients, 62 (91.2%) were successfully treated with the LTD-CBDE technique, and bile leakage was observed in 3 patients (4.4%). The mean operation time was 106 min, and the mean hospital stay was 5.9 days. Among the other 6 patients, 3 were converted to open cholecystectomy due to severe fibrosis, unclear anatomical structure at Calot’s triangle (n = 2) or Mirizze syndrome (n = 1); LCBDE was performed in 3 patients due to cystic duct atresia (n = 2) and low level of flow from the gallbladder duct into the CBD (n = 1). These patients had a smooth postoperative course. In total, 43/68 of the patients presented no radiological evidence of retained CBD stones at the postoperative follow-up (40 patients treated with LTD-CBDE) 1 year later.

Conclusions

The current work suggests that LTD-CBDE for the management of cholelithiasis and secondary choledocholithiasis is a feasible, safe and effective technique with a low complication rate. LTD-CBDE offers another alternative for surgeons to treat patients in similar scenarios. However, additional randomized, controlled studies are needed to demonstrate its efficacy, safety, and impact on CBD stenosis.

Laparoscopic Common Bile Duct Exploration With Primary Closure After Failed Endoscopic Retrograde Cholangiopancreatography Without Intraoperative Cholangiography: A Case Series from a Referral Center in Bogota, Colombia

Background: Despite the effectiveness of laparoscopic common bile duct (CBD) surgery, no case series details the use and advantages of laparoscopic CBD exploration (LCBDE) without use of intraoperative cholangiography (IOC) in endoscopic retrograde cholangiopancreatography (ERCP) failure. Therefore, we present a case series regarding our success with LCBDE in managing CBD stones (CBDSs) using laparoscopic technique without IOC. Materials and Methods: We performed a descriptive retrospective observational study. Patients with CBDSs, alone or along with gallbladder stones, were treated through LCBDE with primary CBD closure after failed ERCP. Results: All patients underwent LCBDE with choledocotomy and primary duct closure. Patients with gallbladder stones underwent laparoscopic cholecystectomy (78%). All procedures were successful, and no conversions occurred. Surgery duration averaged 106 minutes. Intraoperative bleeding averaged 15 cc, and no mortalities occurred. No patients required additional surgery or intensive care unit admission. Hospitalization duration averaged 5 days. Conclusions: Therefore, a laparoscopic approach with primary CBD closure after failed ERCP for complex CBDSs is safe and effective.

Meta-analysis of laparoscopic transcystic versus transcholedochal common bile duct exploration for choledocholithiasis

Background

It is not clear whether laparoscopic transcystic exploration (LTCE) laparoscopic choledochotomy (LCD) is superior in the management of choledocholithiasis. In this meta-analysis, the success of LTCE versus LCD was evaluated.

Methods

Cochrane Central Register of Controlled Trials, Web of Science, Trip, PubMed, Ovid and Embase databases were searched systematically for relevant literature up to May 2017. Studies that compared the success rate of LTCE and LCD in patients with choledocholithiasis were included. PRISMA guidelines were followed. Multiple independent reviewers contributed on a cloud-based platform. Random-effects model was used to calculate odds ratios (ORs) or standardized mean differences (MDs) with 95 per cent confidence intervals. An a priori hypothesis was generated based on clinical experience that LTCE is as successful as LCD.

Results

Of 3533 screened articles, 25 studies comprising 4224 patients were included. LTCE achieved a lower duct clearance rate than LCD (OR 0.38, 95 per cent c.i. 0·24 to 0·59). It was associated with a shorter duration of surgery (MD -0·86, 95 per cent c.i. -0·97 to -0·77), lower bile leak (OR 0·46, 0·23 to 0·93) and shorter hospital stay (MD -0·78, -1·14 to -0·42) than LCD. There was no statistically significant difference in conversion, stricture formation or reintervention rate.

Conclusion

LCD has a higher rate of successful duct clearance, but is associated with a longer duration of surgery and hospital stay, and a higher bile leak rate.

T-Tube Use After Laparoscopic Common Bile Duct Exploration

Background and Objectives:

Laparoscopic common bile duct exploration (LCBDE) has been verified to be an effective technique in treating choledocholithiasis, and T-tube insertion has been widely performed after LCBDE. With growing doubts regarding the effectiveness and safety of T-tube drainage (TTD), it has been suggested to replace such with primary duct closure (PDC). This meta-analysis aimed to evaluate the short- and long-term effectiveness and safety of PDC compared with TTD after LCBDE.

Methods:

The PubMed, Science Citation Index, and Cochrane Central Register of Controlled Trials databases were used to accomplish a systematic literature search for randomized controlled trials and pro-/retrospective cohort studies that compared PDC alone or PDC combined with biliary drainage stenting (PDC+BD) with TTD after LCBDE. A subgroup analysis was established to compare PDC+BD with TTD. RevMan 5.3 was used for the statistical analysis.

Results:

A total of 2552 patients from 26 studies were included. The pooled odds ratio supported PDC, which yielded lower postoperative overall morbidity and incidence of bile leak and bile peritonitis and shorter surgical time and postoperative hospital stay when compared with TTD. In the subgroup analysis, PDC+BD showed significantly better results in terms of postoperative overall morbidity, incidence of bile leak and bile peritonitis, surgical time, and postoperative hospital stay than did TTD. PDC and PDC+BD showed no difference in the incidence of recurrent stones and biliary stricture during the long-term follow-up period compared with TTD.

Conclusion:

PDC alone or PDC+BD is superior to TTD as a duct-closure method after LCBDE.

Human fibrin sealant reduces post-operative bile leakage of primary closure after laparoscopic common bile duct exploration in patients with choledocholithiasis

Context:

Primary closure of the common bile duct (CBD) without drainage is considered a suitable approach after laparoscopic CBD exploration (LCBDE); however, the risk of post-operative bile leakage is high. Up to now, it has not been clear whether human fibrin sealant can reduce post-operative bile leakage of the primary suture.

Aims:

In this study, we evaluated the role of human fibrin sealant in primary closure of the CBD after LCBDE.

Subjects and Methods:

Patients with choledocholithiasis who had undergone primary duct closure of the CBD after LCBDE were divided into two groups according to whether fibrin sealant was used.

Statistical Analysis Used:

Fisher's exact test or the Chi-square test was used for categorical variables to calculate frequencies and percentages between the groups. The Student's t-test was used to compare the means of the continuous variables between the groups.

Results:

The human fibrin sealant group had a lower rate of post-operative bile leakage compared to the other group (P < 0.05). There were no significant differences in additional parameters such as operative time, post-operative stay duration, time to drain removal, bile duct stenosis, acute allergic reaction and overall mortality.

Conclusions:

Human fibrin sealant can reduce post-operative bile leakage in primary closure of CBD after LCBDE in patients with choledocholithiasis.

A predictive nomogram to identify factors influencing the success of a concomitant laparoscopic cholecystectomy with common bile duct exploration for choledocholithiasis

BACKGROUND

Single-staged laparoscopic common bile duct exploration (LCBDE) offers clear benefits in terms of cost and shorter hospitalization stays. However, a failed LCBDE requiring conversion to open surgery is associated with increased morbidity. This study reviewed the factors determining success of LCBDE, and created a predictive nomogram to stratify patients for the procedure.

METHODS

A retrospective analysis of 109 patients who underwent LCBDE was performed. A nomogram was developed from factors significantly associated with conversion to open surgery and validated.

RESULTS

Sixty-two patients underwent a successful LCBDE, while 47 patients required a conversion to open CBDE. The presence of underlying cholangitis (crude OR 2.70, 95% CI: 1.12-6.56, p = 0.017), together with its subsequent interventions, seemed to adversely increase the rate of conversion to open surgery. The predictive factors included in the nomogram for a failed laparoscopic CBDE included prior antibiotic use (adjusted OR (AOR) 2.98, 95% CI: 1.17-7.57, p = 0.022), previous ERCP (AOR 4.99, 95% CI: 2.02-12.36, p = 0.001) and abnormal biliary anatomy (AOR 9.37, 95% CI: 2.18-40.20, p = 0.003).

CONCLUSION

LCBDE is useful for the treatment of choledocholithiasis. However, patients who were predicted to have an elevated risk for open conversion might not be ideal candidates for the procedure.

Learning curve for performing choledochotomy bile duct exploration with primary closure after laparoscopic cholecystectomy

BACKGROUND

Primary closure after laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration (LCBDE) is a safe and effective approach for treating cholecystolithiasis with choledocholithiasis. The aim of this study was to evaluate the learning curve of performing primary closure after LC+LCBDE.

METHODS

We retrospectively identified all patients who underwent primary closure after LC+LCBDE performed by a single surgeon from January 2009 to April 2015 in our institution, and analyzed preoperative, intraoperative, and postoperative data using the cumulative sum (CUSUM) analysis to evaluate the learning curve for this procedure.

RESULTS

Overall, there were 390 patients. The total postoperative complications rate was 7.2%, including bile leakage in 9 (2.3%) patients and retained common bile duct stone in 3 (0.8%) patients. The CUSUM operating time (OT) learning curve was best modeled by the equation: CUSUM_OT = 312.209 × procedure^0.599 × e^{(-0.011×procedure)} + 122.608 (R² = 0.96). The learning curve was composed of two phases, phase 1 (the initial 54 patients) and phase 2 (the remaining 336 patients). A significant decrease in the OT (116.8 ± 22.4 vs. 93.8 ± 17.8 min; p < 0.001) and complication rate (16.7 vs. 5.7%; p < 0.01) including the rate of bile leakage (7.4 vs. 1.5%; p < 0.01) and retained stone (3.7 vs. 0.3%; p < 0.01) was observed between the two phases. In addition, 20 patients had conversion to open surgery. Impacted stones were independently associated with conversion, as indicated by a multivariable analysis.

CONCLUSION

The data suggest that the learning curve of this procedure was achieved in approximately 54 cases. An impacted stone was the only risk factor that affected the conversion rate.

Single-incision laparoscopic common bile duct exploration in 101 consecutive patients: choledochotomy, transcystic, and transfistulous approaches

BACKGROUND

Laparoscopic surgery for choledocholithiasis is still evolving. Only a few reports of single-incision laparoscopic common bile duct exploration (LCBDE) have been published.

METHODS

One hundred and one consecutive patients underwent single-incision LCBDE (SILCBDE) by one surgeon with straight instruments during a 42-month period.

RESULTS

Choledochotomies were performed on 61 patients (60.4%). The success rate of intrahepatic duct exploration was 68.0% (17/25) for patients undergoing transcystic choledochoscopic bile duct explorations following longitudinal cystic ductotomies. The ductal clearance rate was 100%. Eighteen procedures (17.8%) were converted, including one open surgery. Nineteen patients (18.8%) experienced 26 episodes of complications; the majority (19 episodes) were classified as Clavien-Dindo grade I. Excluding those patients with Mirizzi syndrome (McSherry type II), multivariate logistic regressions showed that patients who were older or had complicated cholecystitis had higher procedure conversion rates and that higher modified APACHE II scores, higher white blood cell counts, and longer operative times were independent risk factors for complications. Based on operative times, 20 successful SILCBDEs were needed to get through the learning phase. A higher transcystic approach rate (46.5 vs. 8.3%; P < 0.01) and a shorter operative time (207 ± 62 vs. 259 ± 66 min; P < 0.01) were observed in the experienced phase. Compared with our early series of multi-incision LCBDE, the SILCBDE group had a higher bile duct stone clearance rate (100 vs. 94.4%; P < 0.05) and a higher proportion of patients with concomitant acute cholecystitis (59.6 vs. 22.2%; P < 0.01).

CONCLUSIONS

LCBDE with a 100% ductal clearance rate is possible following an algorithm for various approaches. SILCBDE is feasible under a low threshold for procedure conversion. A transcystic approach should be tried first if indicated, and a longitudinal cystic ductotomy to the cystocholedochal junction is beneficial. Prospective, randomized trials comparing single-incision and multi-incision LCBDE are anticipated.

One-stage laproendoscopic procedure versus two-stage procedure in the management for gallstone disease and biliary duct calculi: a systemic review and meta-analysis

BACKGROUND

Laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography (ERCP) are secure and effective techniques that recently been used to treat bile duct stones. The purpose of this research was to assess the intra-procedural efficacy and postprocedural upshots of the laparoscopic common bile duct exploration plus laparoscopic cholecystectomy (LCBDE) and ERCP plus laparoscopic cholecystectomy (ERCP + LC).

METHODS

All studies contrasting one-stage (LCBDE) with two-stage (ERCP/EST + LC) managements in patients with concomitant gallstones and common bile duct (CBD) stones were included. The primary outcomes were CBD stone clearance, postoperative morbidity, and mortality, while secondary outcomes were conversion with other techniques, duration of stay in hospital, number of procedures used per patient, and operating time. Data were pooled by meta-analysis.

RESULTS

Fourteen studies with 1600 participants were identified. Each arm contains 800 participants. There is no significant difference between the two arms regarding successful CBD stone clearance (RR = 0.96, P = 0.15), mortality (RR = 1.74, P = 0.33), morbidity (RR = 0.89, P = 0.32), conversion to additional procedure (RR = 1.44, P = 0.09), operating time (MD = -1.43 min, P = 0.95), hospital stay (MD = 1.31 days, P = 0.17), and retained stone rate (RR = 1.73, P = 0.38).

CONCLUSIONS

One- and two-stage management had similar efficacy and safety in terms of CBD stone clearance rate, mortality, morbidity, operating time, hospital stay, and retained stone rate. One-stage management may reduce additional procedure.

Management of impacted common bile duct stones during a laparoscopic procedure: A Retrospective Cohort Study of 377 Consecutive Patients

INTRODUCTION

To explore the techniques for managing impacted common bile duct (CBD) stones during laparoscopic common bile duct exploration (LCBDE).

METHODS

We retrospectively analyzed 377 consecutive patients undergoing LCBDE from January 2008 to June 2015. Group 1 was defined as patients with impacted CBD stones. Group 2 included patients without impacted CBD stones. The outcomes of LCBDE were compared between the two groups.

RESULTS

There were 65 patients in Group 1 and 312 patients in Group 2. The incidence of jaundice, abnormal liver function tests, cholangitis and pancreatitis was higher in Group 1. Forty-one patients with small impacted CBD stones were managed using the tipless Nitinol basket. Seventeen patients with large impacted CBD stones and 7 patients with small impacted CBD stones underwent laser lithotripsy via choledochoscopy. None of the patients in Group 1 was converted to open procedures for impacted CBD stones. Operation duration was 13.6 min longer in Group 1 (133.2 min). Postoperative hospital stay was significantly longer in Group 1 (9.7 ± 2.5 d) than in Group 2 (6.3 ± 1.8 d). There was no difference in the overall postoperative complication rate, retained stone rate, and recurrence rate between the two groups.

CONCLUSION

Rational utilization of laser lithotripsy and an appropriate basket in LCBDE may avoid conversion to open procedures in patients with impacted CBD stones.

Laparoscopic common bile duct exploration versus ERCP/stenting and cholecystectomy: Is a single staged procedure better?

Aims: Choledocholithiasis is most common cause of obstructive jaundice. Laparoscopic choledocholithotomy has evolved as an alternative procedure to ERCP/ stenting in the management of choledocholithiasis. This study was aimed to compare the outcomes of laparoscopic CBD exploration with cholecystectomy (group 1) as compared to the conventional two staged procedure involving ERCP/ stenting (group 2). Methods: 60 patients admitted to our department (mean age = 45.52, SD = 17.71, 15 males, 45 females) for the management of choledocholithiasis from April 2014 to October 2015 were included in the study. We reviewed retrospectively the patients' data including age, sex, duration of the surgery, intra-operative and postoperative complications, duration of hospital stay, mortality and condition on follow-up. Results: Group 1 included 30 patients (mean age 50.76, 21 females, 9 males). The average operative time in this group was 110 minutes (96–145), stone clearance rate was 100%, and average hospital stay was 3.2 days (2–9). Group 2 also included 30 patients (mean age 44.36, 24 females, 6 males) with stone clearance rate of 70% (21 out of 30), average operative time 120.7 minutes (90–167), average hospital stay 9.1 (3–30) days and an average of 2.3 procedures per patient. Conclusion: In our study mean operative time, stone clearance rate, average hospital stay and average number of procedures per patient were found to be significantly lower in laparoscopic CBD exploration group. It can be concluded that laparoscopic CBD exploration with cholecystectomy is much safer and cost effective than the conventional two staged procedure involving ERCP/ stenting.

Systematic review with meta-analysis of studies comparing primary duct closure and T-tube drainage after laparoscopic common bile duct exploration for choledocholithiasis

BACKGROUND

With advances in laparoscopic instrumentation and acquisition of advanced laparoscopic skills, laparoscopic common bile duct exploration (LCBDE) is technically feasible and increasingly practiced by surgeons worldwide. Traditional practice of suturing the dochotomy with T-tube drainage may be associated with T-tube-related complications. Primary duct closure (PDC) without a T-tube has been proposed as an alternative to T-tube placement (TTD) after LCBDE. The aim of this meta-analysis was to evaluate the safety and effectiveness of PDC when compared to TTD after LCBDE for choledocholithiasis.

METHODS

A systematic literature search was performed using PubMed, EMBASE, MEDLINE, Google Scholar, and the Cochrane Central Register of Controlled Trials databases for studies comparing primary duct closure and T-tube drainage. Studies were reviewed for the primary outcome measures: overall postoperative complications, postoperative biliary-specific complications, re-interventions, and postoperative hospital stay. Secondary outcomes assessed were: operating time, median hospital expenses, and general complications.

RESULTS

Sixteen studies comparing PDC and TTD qualified for inclusion in our meta-analysis, with a total of 1770 patients. PDC showed significantly better results when compared to TTD in terms of postoperative biliary peritonitis (OR 0.22, 95% CI 0.06-0.76, P = 0.02), operating time (WMD, -22.27, 95% CI -33.26 to -11.28, P < 0.00001), postoperative hospital stay (WMD, -3.22; 95% CI -4.52 to -1.92, P < 0.00001), and median hospital expenses (SMD, -1.37, 95% CI -1.96 to -0.77, P < 0.00001). Postoperative hospital stay was significantly decreased in the primary duct closure with internal biliary drainage (PDC + BD) group when compared to TTD group (WMD, -2.68; 95% CI -3.23 to -2.13, P < 0.00001).

CONCLUSIONS

This comprehensive meta-analysis demonstrates that PDC after LCBDE is feasible and associated with fewer complications than TTD. Based on these results, primary duct closure may be considered as the optimal procedure for dochotomy closure after LCBDE.

Laparoscopic common bile duct exploration

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) is a safe and effective single-stage treatment for choledocholithiasis in the elective setting. The outcomes after LCBDE in the emergency setting are unknown. The aim of this study was to compare the outcomes following elective and emergency LCBDE for choledocholithiasis.

METHODS

Details of all patients who underwent LCBDE for choledocholithiasis between August 2003 and August 2013 were analysed retrospectively. The primary outcome measure was common bile duct (CBD) stone clearance rate. Secondary outcome measures were conversion rate, morbidity, mortality and length of hospital stay.

RESULTS

Some 215 consecutive patients (57 male; median age 65 (range 14-92) years) underwent LCBDE. Some 121 procedures were performed electively and 94 as an emergency. Forty-five patients (48 per cent) presented with obstructive jaundice or cholangitis in the emergency LCBDE group compared with 15 (12·4 per cent) in the elective group (P < 0·001). The CBD stone clearance rate was similarly high in both groups (96 versus 96·7 per cent respectively; P = 0·557). There were no significant differences in conversion rate (6 versus 4·1 per cent), morbidity (5 versus 6·6 per cent), mortality (2 versus 0 per cent) or median length of stay (3 days) between groups. Two patients died, both following emergency LCBDE.

CONCLUSION

LCBDE can be performed safely and effectively in both elective and emergency settings.

Primary closure after laparoscopic common bile duct exploration versus T-tube

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) is now one of the main methods for treating choledocholithiasis accompanied with cholelithiasis. The objective of our study was to assess the safety and effectiveness of laparoscopic primary closure for the treatment of common bile duct (CBD) stones compared with T-tube drainage.

METHODS

Patients who underwent CBD stones were studied prospectively from 2002-2012 in a single center. A total of 194 patients were randomly assigned to group A (LCBDE with primary closure) with 101 cases and group B (LCBDE with T-tube drainage) with 93 cases. Intraoperative cholangiography and choledochoscopy were performed in all patients. Patient demographics, intraoperative findings, postoperative stay, complications, and hospital expenses were recorded and analyzed.

RESULTS

There was no mortality in the two groups. Four patients (3.96%) of group A were converted to open surgery, and three patients (3.23%) in group B. The mean operating time was much shorter in group A than in group B (102.6 ± 15.2 min versus 128.6 ± 20.4 min, P < 0.05). The length of postoperative hospital stay was longer in group B (4.9 ± 3.2 d) than in group A (3.2 ± 2.1 d). The hospital expenses were significantly lower in group A. Three patients experienced postoperative complications, which were related to the usage of the T-tube in group B. The incidences of overall postoperative complications were insignificantly lower in group A.

CONCLUSIONS

Laparoscopic primary closure of CBD is safe and effective for the management of CBD stones, and can be performed routinely as an alternative to T-tube drainage.

Laparoscopic choledochoduodenostomy as an alternate treatment for common bile duct stones after Roux-en-Y gastric bypass

BACKGROUND

After Roux-en-Y gastric bypass (RYGB), the new gastrointestinal configuration does not permit easy endoscopic access to the biliary system in the standard fashion. Common bile duct (CBD) stones have proved to be a challenge for both the surgeon and the endoscopist in this setting. We shall review our experience with laparoscopic choledochoduodenostomy as a treatment of choledocholithiasis after gastric bypass.

METHODS

Between January 2000 and July 2012, 3115 patients underwent RYGB at our institution. Patients were included if they had postoperative CBD stones regardless of previous cholecystectomy. Treatment modality was laparoscopic choledochoduodenostomy. A retrospective chart review of a prospectively collected data was completed, noting the outcomes and complications of the procedure.

RESULTS

Of 3115 patients, 11 patients were included in this study. There were 8 female and 3 male patients with a mean age of 50.5 ± 10.9 (range, 34-66) years. The average time between primary RYGB and choledochoduodenostomy was 39.7 ± 33.8 (range 8-113) months. The average body mass index at primary surgery was 48.2 ± 8.1 (range 38.4-67.4) kg/m(2) and at choledochoduodenostomy was 29.5 ± 6.8 (range 22.7-46.9) kg/m(2). One patient had bile leak that was managed with drain. All patients had resolution of symptoms at a mean follow-up of 24.8 ± 26.9 (range 2-84) months.

CONCLUSION

This small case series suggests that, in experienced hands, laparoscopic choledochoduodenostomy is an option for safe and effective treatment of choledocholithiasis after gastric bypass.

One-step Laparoscopic and Endoscopic Treatment of Gallbladder and Common Bile Duct Stones: Our Experience of the Last 9 Years in a Retrospective Study

The optimal timing and best method for removal of common bile duct stones (CBDS) associated with gallbladder stones (GBS) is still controversial. The aim of this study is to investigate the outcomes of a single-step procedure combining laparoscopic cholecystectomy (LC), intra-operative cholangiography (IOC), and endoscopic retrograde cholangiopancreatography (ERCP). Between January 2003 and January 2012, 1972 patients underwent cholecystectomy at our hospital. Of those, 162 patients (8.2%; male/female 72/90) presented with GBS and suspected CBDS. We treated 54 cases (Group 1) with ERCP and LC within 48 to 72 hours. In 108 patients (Group 2) we performed LC with IOC and, if positive, was associated with IO-ERCP and sphincterotomy. In Group 1, a preoperative ERCP and LC were completed in 50 patients (30%). In four cases (2%), an ERCP and endobiliary stents were performed without cholecystectomy and then patients were discharged because of the severity of clinical conditions and advanced American Society of Anesthesiologists score (III to IV). Two months later a preoperative ERCP and removal of biliary stents were performed followed by LC 48 to 72 hours later. In Group 2, the IOC was performed in all cases and CBDS were extracted in 94 patients (87%). In two cases, the laparoscopic choledochotomy was necessary to remove large stones. In another two cases, an open choledochotomy was performed to remove safely the stones with T-tube drainage. In three cases, conversion was necessary to safely complete the procedure. The mean operative time was 95 minutes (range, 45 to 150 minutes) in Group 1 and 130 minutes (range, 50 to 300 minutes) in Group 2. The mean hospital stay was 6.5 days (range, 4 to 21 days) in Group 1 and 4.7 days (range, 3 to 14 days) in Group 2. Five cases (two in Group 2 and three in Group 1) presented with CBDS at 12 to 18 months after surgery. They were treated successfully with a second ERCP. There was no perioperative mortality. Our experience suggests that when clinically and technically feasible, a single-stage approach combining LC, IOC, and ERCP to the patients diagnosed with chole-choledocholithiasis is indicated. The IO-ERCP with CBDS extraction is a safe and effective method with low risk of postoperative pancreatitis. One-step treatment is more comfortable for the patient and also reduces the mean hospital stay.

Common bile duct stones: analysis of the videolaparoscopic surgical treatment

CONTEXT

About 9% of the Brazilian population has gallstones and the incidence increases significantly with aging. The choledocholithiasis is found around 15% of these patients, and a third to half of these cases presented as asymptomatic. Once the lithiasis in the common bile duct is characterized through intraoperative cholangiography, the laparoscopic surgical exploration can be done through the transcystic way or directly through choledochotomy.

OBJECTIVE

To evaluate the results and outcomes of the laparoscopic treatment of common bile duct lithiasis.

METHODS

Seventy consecutive patients were evaluated. They prospectively underwent the treatment of the lithiasis in the common bile duct and the exploration ways were compared according to the following parameters: criteria on their indication, success in the clearance, surgical complications. It was verified that about ½ of the choledocholithiasis carriers did not show any expression of predictive factors (clinical antecedents of jaundice and/or acute pancreatitis, compatible sonographic data and the pertaining lab tests). The laparoscopic exploration through the transcystic way is favored when there are no criteria for the practice of primary choledochotomy, which are: lithiasis in the proximal bile duct, large (over 8 mm) or numerous calculi (multiple calculosis).

RESULTS

The transcystic way was employed in about 50% of the casuistic and the choledochotomy in about 30%. A high success rate (around 80%) was achieved in the clearance of the common bile duct stones through laparoscopic exploration. The transcystic way, performed without fluoroscopy or choledochoscopy, attained a low rate of success (around 45%), being 10% of those by transpapilar pushing of calculi less than 3 mm. The exploration through choledochotomy, either primary or secondary, if the latter was performed after the transcystic route failure, showed high success rate (around 95%). When the indication to choledochotomy was primary, the necessity for choledochoscopy through choledochotomy to help in the removal of the calculi was 55%. However, when choledochotomy was performed secondarily, in situations where the common bile duct diameter was larger than 6 mm, the use of choledochoscopy with the same purpose involved about 20% of the cases. There was no mortality in this series.

CONCLUSION

The laparoscopic exploration of the common bile duct was related to a low rate of morbidity. Therefore, the use of laparoscopy for the treatment of the lithiasis in the common bile duct depends on the criteria for the choice of the best access, making it a safe procedure with very good results.

Two-stage vs single-stage management for concomitant gallstones and common bile duct stones

AIM: To evaluate the safety and effectiveness of two-stage vs single-stage management for concomitant gallstones and common bile duct stones.

METHODS: Four databases, including PubMed, Embase, the Cochrane Central Register of Controlled Trials and the Science Citation Index up to September 2011, were searched to identify all randomized controlled trials (RCTs). Data were extracted from the studies by two independent reviewers. The primary outcomes were stone clearance from the common bile duct, postoperative morbidity and mortality. The secondary outcomes were conversion to other procedures, number of procedures per patient, length of hospital stay, total operative time, hospitalization charges, patient acceptance and quality of life scores.

RESULTS: Seven eligible RCTs [five trials (n = 621) comparing preoperative endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic sphincterotomy (EST) + laparoscopic cholecystectomy (LC) with LC + laparoscopic common bile duct exploration (LCBDE); two trials (n = 166) comparing postoperative ERCP/EST + LC with LC + LCBDE], composed of 787 patients in total, were included in the final analysis. The meta-analysis detected no statistically significant difference between the two groups in stone clearance from the common bile duct [risk ratios (RR) = -0.10, 95% confidence intervals (CI): -0.24 to 0.04, P = 0.17], postoperative morbidity (RR = 0.79, 95% CI: 0.58 to 1.10, P = 0.16), mortality (RR = 2.19, 95% CI: 0.33 to 14.67, P = 0.42), conversion to other procedures (RR = 1.21, 95% CI: 0.54 to 2.70, P = 0.39), length of hospital stay (MD = 0.99, 95% CI: -1.59 to 3.57, P = 0.45), total operative time (MD = 12.14, 95% CI: -1.83 to 26.10, P = 0.09). Two-stage (LC + ERCP/EST) management clearly required more procedures per patient than single-stage (LC + LCBDE) management.

CONCLUSION: Single-stage management is equivalent to two-stage management but requires fewer procedures. However, patient’s condition, operator’s expertise and local resources should be taken into account in making treatment decisions.

Multivariable analysis of cholecystectomy after gastrectomy: laparoscopy is a feasible initial approach even in the presence of common bile duct stones or acute cholecystitis

BACKGROUND

When performing cholecystectomy after gastrectomy, we often encounter problems, such as adhesions, nutritional insufficiency, and bowel reconstruction. The purpose of this study was to identify the factors related to surgical outcome of these associated procedures, with emphasis on the use of a laparoscopic approach.

METHODS

We retrospectively analyzed data from 58 patients who had a history of cholecystectomy after gastrectomy. Differences between subgroups with respect to operation time, length of postoperative hospital stay, and complications were analyzed. To identify the factors related with outcomes of cholecystectomy after gastrectomy, we performed multivariable analysis with the following variables: common bile duct (CBD) exploration, laparoscopic surgery, gender, acute cholecystitis, history of stomach cancer, age, body mass index, period of surgery, and interval between cholecystectomy and gastrectomy.

RESULTS

We found one case (2.9%) of open conversion. The CBD exploration was the most significant independent factor (adjusted odds ratio (OR), 45.15; 95% confidence interval (CI), 4.53-450.55) related to longer operation time. Acute cholecystitis also was a significant independent factor (adjusted OR, 14.66; 95% CI, 1.46-147.4). The laparoscopic approach was not related to operation time but was related to a shorter hospital stay (adjusted OR, 0.057; 95% CI, 0.004-0.74). Acute cholecystitis was independently related to the occurrence of complications (adjusted OR, 27.68; 95% CI, 1.15-666.24); however, CBD exploration and laparoscopic surgery were not. A lower BMI also was an independent predictor of the occurrence of complications (adjusted OR, 0.41; 95% CI, 0.2-0.87).

CONCLUSIONS

The laparoscopic approach is feasible for cholecystectomy after gastrectomy, even in cases with CBD stones or acute cholecystitis. This approach does not appear to increase operation time or complication rate and was shown to decrease the length of postoperative hospital stay.

Laparoscopic management of CBD stones: an Indian experience

BACKGROUND

Common bile duct stones (CBDS) that are seen in the Asian population are very different from those seen in the west. It is not infrequent to see multiple, large, and impacted stones and a hugely dilated CBD. Many of these patients have been managed by open CBD exploration (OCBDE), even after the advent of laparoscopic cholecystectomy (LC), because these large stones pose significant challenges for extraction by endoscopic retrograde cholangiopancreatography. This series presents the largest experience of managing CBDS using a laparoscopic approach from Indian subcontinent.

METHODS

Between 2003 and 2009, 150 patients with documented CBDS were treated laparoscopically at a tertiary care hospital in New Delhi. Of these, 4 patients were managed through transcystic route and 140 through the transcholedochal route.

RESULTS

There were 34 men and 116 women patients with age ranging from 15 to 72 years. The mean size of the CBD on ultrasound was 11.7 ± 3.7 mm and on MRCP 13.8 ± 4.7 mm. The number of stones extracted varied from 1 to 70 and the size of the extracted stones from 5 to 30 mm. The average duration of surgery was 139.9 ± 26.3 min and the mean intraoperative blood loss was 103.4 ± 85.9 ml. There were 6 conversions to open procedures, 1 postoperative death (0.7%), and 23 patients (15%) had nonfatal postoperative complications. Three patients had retained stones (2%) and one developed recurrent stone (0.7%).

CONCLUSIONS

Even in patients with multiple, large, and impacted CBDS, there is scope for a minimally invasive procedure with its attendant benefits in the form of laparoscopic CBD exploration (LCBDE).

Single-step treatment of gall bladder and bile duct stones: a combined endoscopic-laparoscopic technique

INTRODUCTION

The advent of endoscopic techniques changed surgery in many regards. In the management of cholelithiasis; laparoscopic cholecystectomy (LC) is today the treatment of choice. This has created a dilemma in the management of choledocholithiasis. Today a number of options exist, including endoscopic sphincterotomy (ES) before LC in patients with suspected common bile duct (CBD) stones, laparoscopic common bile duct exploration (LCBDE) by the transcystic approach or laparoscopic choledocotomy, open CBD exploration and postoperative ERCP. A major concern regarding both pre- and postoperative extraction of CBD stones (CBDS) by the ERCP is the risk of development of pancreatitis, also more than 10% of the preoperative ERCP is normal. More recently the alternative technique of combined LC with intraoperative ERCP and ES is emerging in an attempt to manage cholecysto-choledocholithiasis in a single-step procedure.

OBJECTIVES

The aim of this work was to assess the treatment of common bile duct stones (CBDS) in a one-stage operation by laparoscopic cholecystectomy (LC) and intraoperative endoscopic retrograde cholangiopancreatography (LC+IO-ERCP) and endoscopic sphincterotomy (ES).

PATIENTS AND METHODS

This study was carried out on 45 patients with gall bladder stones and with suspected or confirmed CBDS at the Gastrointestinal Surgery Unit in the Main Alexandria University Hospital. They were treated by a single-step procedure combining LC and IO-ERCP. Laparoscopic intraoperative cholangiography (IOC) was carried out to confirm the presence of CBDS. A soft-tipped guide-wire was passed through the cystic duct and papilla into the duodenum. A papillotome was inserted endoscopically over the guide-wire. Endoscopic sphincterotomy was performed and the stones were extracted with a retrieval balloon or with a Dormia basket. The surgical operating time, surgical success rate, postoperative complications, retained CBDS, and postoperative length of hospital stay were assessed.

RESULTS

There were 30 females and 15 males. Their mean age was 45.07+11.3 years (ranging from 27 to 65 years). Twenty-seven patients had confirmed CBDS by preoperative ultrasound (US) and/or MRCP. Eighteen patients were suspected for CBDS on clinical, laboratory and/or US basis. Conversion to open cholecystectomy occurred in one case due to severe adhesions at the Calot's triangle. IOC revealed the presence of CBDS in 36 patients. IO-ERCP with ES was performed successfully in 33 patients and stones were extracted endoscopically. Passage of the guide-wire through the papilla failed in three patients. Cholecystectomy was completed laparoscopically in 44 patients. The mean operative time was 119+14.4 min (ranging from 100 to 150 min). Minor postoperative complications occurred in 15 patients. No postoperative complications related to the procedure, i.e., pancreatitis, bleeding, perforation, were encountered. Patients regained their bowel motion on the next day and were discharged after a mean hospital stay of 2.55+0.89 days. None of the patients presented on the postoperative follow-up with symptoms, signs, laboratory or radiological evidence of retained CBDS. The mean duration of the postoperative follow-up was 9+4.07 months (ranging from 3 to 14 months).

CONCLUSION

The current study suggests that LC+IO-ERCP for the management of cholecysto-choledocholithiasis is a safe and aneffective technique with a low rate of post-ERCP pancreatitis. It offers another alternative for surgeons especially those who do not practice LCBDE to treat patients in a single setting. However, additional studies with larger patient populations are needed keeping in mind that the limiting characteristic is the proximity and availability of the endoscopic settings.

Stone clearance and risk factors for failure in laparoscopic transcystic exploration of the common bile duct

BACKGROUND

Laparoscopic cholecystectomy has become a gold standard globally. At the time of surgery, 5 to 10% of patients have coexisting stones in the common bile duct (CBD). There are several alternatives in treating these patients. We have chosen to try to extract the CBD stones at the primary operation by laparoscopic transcystic CBD exploration.

METHODS

During the years 1994-2002 laparoscopic attempt of exploration of the CBD was made in 207 patients. Data was prospectively collected in a database, and was analyzed using unconditional logistic regression for risk factor analysis.

RESULTS

In 155 of the 207 patients an attempt of transcystic CBD exploration was made and it was successful in 132 cases (85%). The median operating time was 184 minutes (range 89-384 minutes) and the median postoperative hospital stay was one day (range 1-31 days). The odds ratio for failure in stone clearance among patients with a bile duct diameter greater than 6 mm was 6.90 (95% confidence interval (CI): 0.87-54.61) compared to patients with a bile duct diameter of 6 mm or less. There was a significant threefold increase in risk among patients with stones of greater than 5 mm diameter compared to patients with stones 5 mm or less.

CONCLUSIONS

The laparoscopic transcystic exploration of the CBD had a high frequency of stone clearance and low morbidity in the present study. Moreover, large stones are a risk factor for failure in stone clearance.

Laparoscopic common bile duct exploration using a rigid nephroscope

Background

Patients with cholelithiasis and choledocholithiasis are increasingly managed with laparoscopic bile duct exploration and cholecystectomy. Large impacted bile duct stones continue to defy laparoscopic extraction. This study explored the feasibility of laparoscopic bile duct clearance using a rigid nephroscope, which is suited to extracting large stones.

Method

This prospective study recruited patients with large bile duct stones and a bile duct wider than 8 mm on ultrasonography. In addition to standard ports for laparoscopic cholecystectomy, a custom-made 9-mm port was introduced in the epigastrium for the rigid nephroscope, which was negotiated into the bile duct through a choledochotomy. Rigid graspers and lithotripters were introduced through the nephroscope to fragment and remove the calculi.

Results

Between December 2005 and September 2008, 18 patients had nephroscope-guided bile duct exploration (mean(s.d.) age 49(13·9) years, bile duct diameter 11·3(2·3) mm). Three patients had solitary stones and 15 had multiple calculi. Most of the stones were removed with graspers, but the lithotripter was required in five patients. The mean(s.d.) hospital stay was 6(2·3) days. Two patients required postoperative endoscopic retrograde cholangiopancreaticography for residual stones.

Conclusion

The rigid nephroscope was useful for laparoscopic bile duct exploration, particularly for large impacted stones.

[Advantages of laparoscopic stented choledochorrhaphy. Six years experience]

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) is nowadays a valid option in the management of common bile duct stones. T tube and primary closure have been used to close the choledochotomy, but these methods are not free of complications. We present our experience with the stented choledochorrhaphy.

MATERIAL AND METHOD

We retrospectively reviewed the data of 104 patients, who underwent LCBDE between January 1999 and February 2007. T tube was used in the first period. From July 2001 the method of choice has been the closure of the CBD over an endoprosthesis placed under direct view and later removed by gastroscopy.

RESULTS

The technique was performed on 70 consecutive patients. Median operation time was 90 minutes. There was no conversion to open surgery. Stones could not be retrieved in 4.2% of patients. The median hospital stay was 4 days. Morbidity was 7%, although only 2.8% was related to the stent (acute pancreatitis). Postoperative mortality was 1.4%.

CONCLUSIONS

The stented laparoscopic choledochorrhaphy allows an efficient biliary decompression, and seems to avoid the complications of the T tube and primary closure. This method should be considered as a valid option after choledochotomy.

Laparoscopic choledochotomy in management of choledocholithiasis

PURPOSE

Laparoscopic choledochotomy on patients indicated for common bile duct exploration was carried out according to an algorithm for managing choledocholithiasis. This study describes retrospectively our method and evaluates a new cystic duct biliary decompression cannula (J-tube) as an alternative to the T-tube.

METHODS

Patients with confirmed choledocholithiasis (n=46) underwent laparoscopic choledochotomy. The T-tube was inserted in cases with suspected retained stones after common bile duct clearance, and the J-tube (950-mm long, 4 Fr) with a tapered and J-shaped segment at the distal end was inserted in other cases.

RESULTS

Only 1 case was converted to open surgery (success rate, 97.8%); the J-tube was inserted in 30 patients and the T-tube in 15. The median operation time, hospital stay, and the interval until removal of the tube were significantly shorter with J-tube than with T-tube cases. Bile leakage after surgery occurred in 4 J-tube and 2 T-tube cases with one residual stone in each case.

CONCLUSIONS

The transcystic decompression tube is easily and safely inserted with the J-kit. Among several strategies currently available for the management of choledocholithiasis, laparoscopic choledochotomy with the use of the J-tube is one of the safest and most feasible methods.

Evaluation of laparoscopic treatment of common bile duct stones in a prospective series of 505 patients: indications and results

BACKGROUND

The aim of this prospective study was the evaluation of the laparoscopic treatment of common bile duct stones (CBDS) and its indications.

METHODS

Five hundred five patients who underwent laparoscopic treatment of CBDS from October 1990 to September 2006 were included in the prospective study. The mean age of the patients was 63 years (range = 19-93). Four hundred fifteen patients were classified ASA I and ASA II and 90 were ASA III and ASA IV. CBDS were suspected or diagnosed preoperatively in 373 patients (73.8%) and diagnosed at intraoperative cholangiography (IOC) in 132 patients (26.2%). A transcystic duct extraction (TCDE) was attempted in 254 patients (50.4%) and a primary choledochotomy in 251 patients (49.6%). Biliary drainage after choledochotomy was used in 148 cases (48.8%).

RESULTS

TCDE was successful in 191 cases (75.2%). The 63 failures were managed by laparoscopic choledochotomy in 53 cases and by endoscopic sphincterotomy (ES) in 10 cases. A choledochotomy was thus performed in 304 patients and successful in 295 cases (97%). The nine failures were managed by six conversions to laparotomy (2%) and three postoperative ES. The overall success rate was 96.2%. The morbidity rate was 7.9% with 4.8% of local complications and 3.1% of general complications. The mortality rate was 1%. There were 14 residual stones (2.8%) that were managed by a second laparoscopy in two cases and by ES in 12 cases with four failures managed by laparotomy in one case and laparoscopy in three cases.

CONCLUSION

Laparoscopic management of CBDS was effective in more than 96% of cases and particularly safe in ASA I and ASA II patients. It has the advantage over ES followed by laparoscopic cholecystectomy (LS) to be a one-stage procedure.

Primary closure of the common bile duct in open laparotomy for common bile duct stones

It is common these days to treat common bile duct (CBD) stones using endoscopic techniques. However, severe complications sometimes lead to death despite the great benefit of these techniques. If the patient has many and/or large stones, it can take considerable time for duct clearance, and this is associated with high costs. Therefore, we do not hesitate to choose surgical procedures when necessary. In this study, our aim was to evaluate the usefulness of primary closure of the CBD in open laparotomy for CBD stones. Thirty-four patients with CBD stones were operated on by open laparotomy; primary closure was done in 17 patients (group PC), and T-tube insertion was done in 17 (group TT). We compared the patients' medical records, clinical features, laboratory data, complications, and postoperative hospital admission days. There were no significant intergroup differences in patients' medical records, clinical features, or laboratory data, except for the number of CBD stones. There were no differences in complications. All complications were minor and needed no extra care. The number of postoperative hospital admission days showed a significant difference: 18.3 days in group PC and 31.5 in group TT. There are so many methods to treat CBD stones now that the selection of the procedure can be important for the patient's benefit. We prefer primary closure, to get better quality of life postoperatively and to avoid further operations and any severe complications.

Management of common bile duct stones in a rural area of the United States

BACKGROUND

Laparoscopic common bile duct exploration has been reported to be highly successful and cost-effective. It remains unknown to what extent the procedure is used in routine surgical practice.

METHODS

We conducted a survey of general surgeons practicing in a rural area of the United States. The type of practice, laparoscopic training, performance of cholangiography, and preferred approach to choledocholithiasis were elicited.

RESULTS

Sixty-eight of 207 surveys (33%) were returned. Thirty respondents (45%) indicated that they perform laparoscopic common bile duct explorations. The likelihood of laparoscopic common bile duct exploration increased with a higher number of cholecystectomies per year (p < 0.05, chi-square) but was independent of training or routine cholangiography. The preferred approach to a patient with choledocholithiasis was endoscopic retrograde cholangiopancreatography (75%), followed by laparoscopic (21%) and open exploration (4%). Reasons for not performing laparoscopic exploration were time (58%), equipment (24%), good gastrointestinal backup (6%), reimbursement (3%), increased morbidity (1.5%), lack of skill (1.5%), and other/no reason (18%).

CONCLUSION

Although 45% of practicing surgeons indicated that they perform laparoscopic common bile duct explorations, only 21% practiced it as their preferred approach. Time constraints and lack of equipment are the main factors preventing the application of the laparoscopic technique toward choledocholithiasis.

Early versus delayed single-stage laparoscopic eradication for both gallstones and common bile duct stones in mild acute biliary pancreatitis

Several studies addressed that preoperative endoscopic retrograde cholangiopancreatography (ERCP) for common bile duct (CBD) clearance, followed by interval laparoscopic cholecystectomy (two-stage approach), constitutes the most common practice in cases of uncomplicated mild acute biliary pancreatitis. Between June 1998 and December 2002, 44 patients (35 females and 9 males with a median age of 62 years) suffering from uncomplicated mild acute biliary pancreatitis were treated in our unit. All patients were electively submitted to surgery after subsidence of the acute symptoms, and for definitive treatment we favored the single-stage laparoscopic management, avoiding preoperative ERCP. All patients underwent laparoscopic cholecystectomy plus fluoroscopic intraoperative cholangiogram (IOC). If filling defect(s) were detected in the IOC, a finding suggestive of concomitant choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) was added in the same sitting. Twenty patients were operated upon within 2 weeks since the attack of the acute symptoms and constitute the early group (n=20), whereas 24 patients underwent an operation later on and constitute the delay group (n=24). We retrospectively compare the safety, effectiveness, and outcome after the single-stage laparoscopic management between the two groups of patients. Laparoscopic cholecystectomy alone constituted the definitive treatment in 38 patients, while an additional LCBDE was performed in the remaining 6 patients (14%), and all operations were achieved laparoscopically. There was no statistically significant difference between the groups in terms of operative time, incidence of concomitant choledocholithiasis, morbidity rate, and postoperative hospital stay. During the follow-up, none of the patients experienced recurrent pancreatitis. In uncomplicated mild acute biliary pancreatitis cases, a single-stage definitive laparoscopic management, avoiding preoperative ERCP, can be safely performed during the same admission, after the improvement of symptoms and local inflammation. Postoperative ERCP should be selectively used in patients in whom the single-stage method failed to resolve the problem.

Cost-effective method for laparoscopic choledochotomy

BACKGROUND

Recent reports have noted that postoperative complications following open or laparoscopic choledochotomy for common bile duct (CBD) exploration are mainly related to the T-tube presence, and that there has been no trend of decrease in the laparoscopic era. Laparoscopic endobiliary stent placement with primary closure of the CBD has been proposed as a safe and effective alternative to T-tube placement.

METHODS

Between January 1999 and January 2003, 53 consecutive patients suffering from proven choledocholithiasis underwent laparoscopic common bile exploration (LCBDE) via choledochotomy. In the early period, a T-tube was placed at the end of the procedure (group A, n = 32) while, from June 2001 onwards, laparoscopic biliary stent placement and primary CBD closure were chosen as the drainage method (group B, n = 21).

RESULTS

Six patients developed T-tube-related complications postoperatively. Univariate analysis revealed statistically significant lower morbidity rate and shorter postoperative hospital stay for the stent group. Although not statistically significant, a median saving of 780 UK pounds per patient was observed in the stent group.

CONCLUSION

Biliary endoprosthesis placement following laparoscopic choledochotomy avoids the well-known complications of a T-tube, leading to a shorter postoperative hospital stay. The method is safe and effective and it should also be considered as cost-effective compared to T-tube placement. Further studies are required in order to document cost-effectiveness of the method.

Feasibility of laparoscopic common bile duct exploration in a rural centre

BACKGROUND

Laparoscopic common bile duct exploration has emerged as a preferred option for the management of choledocholithiasis. The present study sought to review the feasibility of this technique in a rural centre.

METHODS

A comprehensive retrospective review was undertaken of all patients who underwent surgical treatment of biliary calculi in Lismore, NSW (Australia), between January 1996 and December 2002.

RESULTS

During the study period, 1567 consecutive patients underwent laparoscopic cholecystectomy, of whom 82 (5.2%) had choledocholithiasis identified at intraoperative cholangiography. A total of 86 laparoscopic common bile duct explorations were undertaken in these patients, 37 (43%) via a transcystic approach, and 49 (57%) via a laparoscopic choledochotomy. All common bile duct calculi were successfully removed in 78 cases, representing an overall duct clearance rate of 90.7%. Complications were noted in seven patients, a morbidity rate of 8.5%. Median operative time for the procedure over the study period was 173 min. Median hospital stay was 6 days for all patients.

CONCLUSIONS

Laparoscopic common bile duct exploration can be successfully undertaken in a rural setting by general surgeons who have appropriate laparoscopic experience, and should be the procedure of choice for the management of choledocholithiasis in these patients. It should not be restricted to specialized surgical departments in major referral centres.

Advantages of laparoscopic stented choledochorrhaphy over T-tube placement

Background

Postoperative complications after laparoscopic choledochotomy are mainly related to the T tube. Both laparoscopic endobiliary stent placement with primary closure of the common bile duct (CBD) and primary closure of the CBD without drainage have been proposed as safe and effective alternatives to T-tube placement.

Methods

This was a retrospective analysis of data collected prospectively on 53 consecutive patients suffering from proven choledocholithiasis who underwent laparoscopic CBD exploration through a choledochotomy between January 1999 and January 2003. In the early period a T-tube was placed at the end of the procedure (n = 32). Biliary stent placement and primary CBD closure was performed from June 2001 (n = 21).

Results

There were no significant differences in epidemiological characteristics, preoperative factors or intraoperative findings between the groups. Seven patients developed complications, six in the T-tube group and one in the stent group. Univariate analysis revealed a significantly lower morbidity rate and shorter postoperative hospital stay in the stent group.

Conclusion

Placement of a biliary endoprosthesis after laparoscopic choledochotomy achieves biliary decompression, and avoids the complications of a T tube, leading to a shorter postoperative hospital stay. The method is a safe and effective alternative method of CBD drainage after laparoscopic choledochotomy.

Intraoperative endoscopic retrograde cholangiopancreatography (ERCP) to remove common bile duct stones during routine laparoscopic cholecystectomy does not prolong hospitalization: a 2-year experience

BACKGROUND

There is still some controversy regarding the optimal timing and best method for the removal of common bile duct stones (CBDS). Intraoperative endoscopic retrograde cholangiopancreaticography (IO-ERCP) is an alternative method that should be considered for this procedure. The aim of our study was to investigate the clinical outcome of a single-step procedure (IO-ERCP) to remove CBDS, thereby combining two existing high-volume clinical modalities-i.e., laparoscopic cholecystectomy (LC) and ERCP.

METHODS

Between January 2000 and December 2001, 674 patients, 192 male and 482 female, underwent cholecystectomy at our hospital. There were 612 LC (90.8%), 37 converted procedures (5.5%), and 25 open operations (3.7%). In 592 of the patients, (87.8%) intraoperative cholangiography (IOC) was performed. In 34 (5.7%) of those who had and IOC, an IO-ERCP was performed. While the surgeon waited for the endoscopist, care was taken to introduce a thin guidewire through the lOC catheter and pass it through the sphincter of Oddi, out into the duodenum. This complementary procedure greatly facilitated the subsequent cannulation of the bile ducts.

RESULTS

The cannulation frequency of the CBD was 100%. Common bile duct stones were successfully extracted in 93.5%. Endoscopic sphincterotomy (EST), followed by the insertion of a plastic endoprosthesis, was performed in two patients with remaining stones. The CBD of these two patients was cleared by postoperative ERCP. None of the patients developed postoperative pancreatitis. The operating time was prolonged as compared with the time for LC (192 vs 110 mins; p < 0.05). The length of hospitalization for IO-ERCP patients did not differ from that for patients undergoing cholecystectomy alone (2.6 vs 2.1. days; NS).

CONCLUSIONS

The study suggests that elective IO-ERCP is a safe and efficient method for removing CBDS that has a low risk of inducing postoperative pancreatitis and does not prolong postoperative hospitalization. This technique enables perioperative extraction of CBDS without open or laparoscopic surgical exploration of the CBD and can be used safely in a routine clinical setting.

Single-stage definitive laparoscopic management in mild acute biliary pancreatitis

BACKGROUND

Population-based studies have shown that nearly one third of patients with acute biliary pancreatitis undergo endoscopic retrograde cholangiopancreatography (ERCP) before undergoing laparoscopic cholecystectomy (LC) (two-stage approach). The present study was designed to evaluate the safety of single-stage laparoscopic management to avoid preoperative ERCP.

MATERIALS AND METHODS

Between June 1998 and June 2002, 35 female patients and 10 male patients (median age, 59 years) with uncomplicated mild acute biliary pancreatitis were studied prospectively and reviewed retrospectively. LC with fluoroscopic intraoperative cholangiography (IOC) or with fluoroscopic IOC and laparoscopic CBD exploration in cases of concomitant choledocholithiasis was performed as the definitive treatment (single-stage approach). Patients underwent surgery electively when symptoms had subsided and laboratory parameters had improved.

RESULTS

LC alone was performed in 39 patients, and an additional laparoscopic CBD exploration was performed in the remaining six. In one patient, IOC yielded a false-positive result. CBD stones were detected in four cases, and debris in the CBD in one case, for an 11% incidence of concomitant choledocholithiasis. The conversion rate was zero, and single-stage laparoscopic treatment was successful in all cases. The overall morbidity rate was 4%. The 30-day postoperative mortality rate was zero.

CONCLUSION

Although preoperative ERCP and sphincterotomy still have a role in complicated cases of mild acute biliary pancreatitis, laparoscopic single-stage definitive treatment is feasible and safe in uncomplicated cases of disease when local experience is available.

Endolaparoscopic rendezvous treatment: a satisfying therapeutic choice for cholecystocholedocolithiasis

BACKGROUND

There are many different strategies for the treatment of the main bile duct lithiasis. When lithiasis of the biliary tract is suspected at a preoperative stage, we can treat patients with sequential treatment: endoscopic netrograde cholangiopancreatography followed by laparoscopic cholecystectomy. If common bile duct-lithiasis is recognized at an intraoperative stage, many options for treatment exist, one of which is intraoperative retrograde endoscopic sphincterotomy (ES) (laparoendorendezvous).

METHODS

We report our experience using the aforementioned technique with 58 patients affected by cholelithiasis and complex Common bile duct disease who underwent laparoscopic cholecystectomy and intraoperative ES consecutively from March 1996 to May 2000. Of the 58 patients, 43 were affected by cholecystocholedocolithiasis: 12 by previously described lithiasis plus stenosant papillitis, 2 also by a pancreas head cancer, and 1 by cancer of the papilla.

RESULTS

The combined technique was performed in 86% of the cases. Six patients required conversion to open surgery. In two other patients, laparoscopic choledocotomy was performed with positioning of a Kehr-tube for an ampulla-impacted lithiasis.

CONCLUSIONS

Intraoperative ES offers a valid approach to the treatment of cholecystocholedocolithiasis in one session. Furthermore, it represents a valid alternative to transcholedocical laparoscopic treatment of cholelithiasis and complex common bite duct pathology.

A balanced approach to choledocholithiasis

BACKGROUND

We set out to review and evaluate the results of an algorithm for managing choledocholithiasis in patients undergoing laparoscopic cholecystectomy.

METHODS

We performed retrospective review of patients with choledocholithiasis at the time of laparoscopic cholecystectomy (LC) between March 1993 and August 1999. All patients were operated on under the direction of one surgeon (M.E.A), following a consistent algorithm that relies primarily on laparoscopic transcystic common bile duct exploration (TCCBDE) but uses laparoscopic choledochotomy (LCD) when the duct and stones are large or if the ductal anatomy is suboptimal for TCCBDE. Intraoperative endoscopic retrograde sphincterotomy (ERS) is done if sphincterotomy is required to facilitate common bile duct exploration (CBDE). Postoperative endoscopic retrograde cholangiopancreatography (ERCP) is utilized when this fails. Preoperative ERCP is used only for high-risk patients.

RESULTS

A total of 728 LC were performed, and there were 60 instances (8.2%) of choledocholithiasis. Primary procedures consisted of 47 TCCBDE; 37 of them required no other treatment. In five cases, the stones were flushed with no exploration. Intraoperative ERS was performed three times as the only form of duct exploration. LCD was utilized twice; one case also required intraoperative ERS, and the other had a postoperative ERCP for stent removal. One patient with small stones was observed, with no sequelae. Preoperative ERCP was done twice as the primary procedure. Of the 10 cases that were not completely cleared by TCCBDE, three had a postoperative ERCP and seven had an intraoperative ERS, one of which required a postoperative ERCP. There were three complications (6%) related to CBDE, with no long-term sequelae. There were four postoperative complications (6.7%) and no deaths. The mean number of procedures per patient was 1.12. The average postoperative hospital stay was 1.8 days (range, 0-14).

CONCLUSIONS

Choledocholithiasis can be managed safely by laparoscopic techniques, augmenting with ERCP as necessary. This protocol minimizes the number of procedures and decreases the hospital stay.

Management of Bile Duct Stones in 1572 Patients Undergoing Laparoscopic Cholecystectomy

Evidence of bile duct stones (BDSs) was identified on routine cholangiogram in 136 (8.7%) of 1572 patients undergoing laparoscopic cholecystectomy from March 1989 through March 1997. Forty-two (30.9%) were unsuspected. All patients with evidence of BDSs underwent laparoscopic bile duct exploration (LBDE). Initially, a standard choledochotomy with T-tube drainage as in the open approach was used. Later, transcystic duct exploration was added to the algorithm. The algorithm evolved into an ongoing treatment protocol study that was initiated in March 1992. Through March 1997, 100 patients underwent LBDE based on the protocol. The study is divided into two groups. Group A comprises the total 136 patients undergoing LBDE, including those in the protocol study. A subgroup, Group B, comprises only the 100 patients in the protocol study. In Group A, LBDE was successful in 114 patients (83.8%). Stones were missed in seven patients and left behind for spontaneous passage or later retrieval in six patients. Eleven patients (8.1%) were converted to open. There were 13 major complications (9.6%), including the seven missed stones and two deaths. In Group B, LBDE was successful in 94 per cent. Stones were missed in one patient and intentionally left behind in four patients. One patient was converted to open. There were seven major complications (7%), including one of the missed stones and one death. Using the protocol algorithm and the techniques described, BDSs can be effectively managed laparoscopically at the time of cholecystectomy in approximately 94 per cent of cases.

[Laparoscopic treatment of common bile duct lithiasis. Study of 56 cases]

AIM OF THE STUDY

The aim of this retrospective study was to report the results of the laparoscopic management of common bile duct stones in an unicentric series of 56 patients.

PATIENTS AND METHOD

From January 1993 to April 1998, 56 patients, 38 women, 18 men (mean age: 59.2 years), underwent a common bile duct exploration for lithiasis through a laparoscopic approach. The patients were hospitalised for angiocholitis (n = 13), cholecystitis (n = 11), biliary pain (n = 29, nine with jaundice), pancreatitis (n = 3), abnormality of hepatic profile (n = 1). All the patients underwent an intraoperative cholangiography. Removal of the stones was tried in 50 cases through a choledochotomy, in four through the cystic duct, using Mirrizi forceps, or Dormia and Fogarty catheters in case of failure. External biliary drainage and postoperative cholangiography were done systematically. The average diameter of the common bile duct was 10.5 mm (6-20 mm).

RESULTS

In 41 patients, removal of the stones was laparoscopically successful. In 11 patients, a conversion into laparotomy was necessary for several reasons. In three patients with common bile duct of small diameter, the stones were abandoned for a further endoscopic sphincterotomy. There was no mortality and the morbidity rate was 7%. The mean postoperative hospital stay was 8.6 days (4-20) for all the series and 7.8 days in case of successful laparoscopic management.

CONCLUSION

In 73% of the patients, the treatment of the common bile duct lithiasis could be achieved laparoscopically, but conventional approach and endoscopic sphincterotomy are still useful in case of failure of the laparoscopic management.

Eight years' experience with the use of a transcystic common bile duct duodenal double-lumen catheter for the treatment of choledocholithiasis

BACKGROUND

We have previously reported an alternative technique for treatment of choledocholithiasis found at laparoscopic cholecystectomy (LC) that can be considered with selected patients. This study was undertaken to update our experience with this alternative technique, which makes serial postoperative cholangiograms possible and facilitates stone extraction by assuring access to the common bile duct so that a guidewire-assisted endoscopic retrograde sphincterotomy can be performed.

METHODS

In the period between 1989 and 1997, prospective data were maintained on 1043 consecutive patients who underwent LC by a single surgeon. Fifty-two patients with abnormal cholangiograms were managed with a percutaneously placed double-lumen catheter threaded through the cystic duct and advanced into the duodenum.

RESULTS

Five attempts failed, 3 because of failure to pass the catheter and 2 because of catheter dislodgement. Of the 47 remaining patients, 2 underwent intraoperative endoscopic sphincterotomies using this alternative technique and 45 had cholangiograms repeated at 10 to 14 days. Twenty-three had negative cholangiograms, thus avoiding further procedures or unnecessary sphincterotomies because of spontaneous stone passage or initial false-positive cholangiograms. The remaining 22 had positive cholangiograms. Eighteen ultimately underwent sphincterotomies with stone extraction using a guidewire placed through the catheter. The other 4 had negative cholangiograms after serial follow-up, presumably because of spontaneous stone passage.

CONCLUSIONS

The use of a transcystic double-lumen catheter passed through the ampulla of Vater is an effective and safe alternative for the management of choledocholithiasis discovered during LC.