Upfront Laparoscopic Management of Common Bile Duct Stones: What Are the Risk Factors of Failure?

Feasibility and outcome of transcystic laparoscopic common bile duct exploration as first-line treatment for common bile duct stones: a retrospective cross-sectional study

BACKGROUND

For treatment of common bile duct stones (CBDS), guidelines recommend a one-stage approach, including laparoscopic common bile duct exploration (LCBDE) or intraoperative endoscopic retrograde cholangiopancreatography (intraERCP). Studies show favourable outcomes with transcystic LCBDE (tLCBDE), but this technique is not widely adopted. The use of tLCBDE may be limited by several factors, but to what degree is unknown. The aim of this study is to examine the feasibility and, secondarily, outcomes of tLCBDE for patients undergoing removal of CBDS and laparoscopic cholecystectomy (LC) when tLCBDE is the first-line treatment.

METHOD

A retrospective cross-sectional study including patients with removal of CBDS and LC at Horsens Regional Hospital during June 2017-March 2022. We classified patients into three groups: tLCBDE, preoperative ERCP (preERCP), and other procedures. The reasons for not performing tLCBDE were registered from medical charts. In the tLCBDE and the preERCP group, we registered clearance rate, postoperative complications, and subsequent ERCP.

RESULTS

In total, 229 patients received a procedure due to CBDS, of which 73% were emergency procedures. The groups were as follows: 179 (78%) tLCBDE, 25 (11%) preERCP, and 25 (11%) other procedures. preERCP was chosen due to the patient being unfit for emergency surgery, tLCBDE not being technically possible, and other reasons. Other procedures were chosen, because tLCBDE was not technically possible, lack of equipment or qualified surgeon, and other reasons. In the tLCBDE group, 94% of patients with CBDS were cleared, 5.6% had a complication of Clavien-Dindo grade ≥ 3, and 3.9% patients needed a subsequent ERCP.

CONCLUSION

tLCBDE is feasible, safe, and effective treatment which can be performed in the majority of patients with CBDS and should be considered an equivalent to ERCP or choledochotomy as first-line treatment of patients with CBDS. As some patients require ERCP or choledochotomy, tLCBDE should not be the sole treatment available.

Laparoscopic common bile duct exploration for choledocholithiasis on an emergency setting

INTRODUCTION

Choledocholithiasis is a common clinical condition that may present with severe complications such as acute cholecystitis or cholangitis, requiring treatment on an emergency setting. This situation is frequently managed following an endoscopic approach by ERCP. However, access to emergent endoscopic biliary decompression is lacking in most centers. In addition, experience in laparoscopic common bile duct exploration (LCBDE) in elective patients is increasing revealing good outcomes. This study analyzes the outcomes of LCBDE management of choledocholithiasis performed on an emergency setting (ELCBDE).

MATERIALS AND METHODS

We performed a descriptive, prospective, single-center study of patients undergoing ELCBDE from January 2020 to December 2023. Demographic, clinical, and surgical variables were recorded. Postoperative complications (Dindo-Clavien), the success of stone clearance, and the occurrence of bile leaks (ISGLS) were also documented. Recurrence of choledocholithiasis and the association between severe complications and Charlson Comorbidity Index (CCI) were analyzed.

RESULTS

A total of 31 patients were included. Median age was of 78 years. The transductal (TD) approach was employed in all cases without conversion to open surgery. The median CCI was 4. Intraoperative cholangiography was performed in 19.4% of cases and over 4 stones were extracted in 35.5% of the patients. Primary closure of the choledochotomy was achieved in 93.5% of patients. Severe complications (DindoClavien ≥ 3) occurred in 6.5% of patients. There were no reintervention or technique related deaths. Stone recurrence was not detected. The mean hospital stay was 4 days. Neither CCI nor advanced age was significantly associated with severe complications development (p > 0.05).

CONCLUSIONS

ELCBDE plus LC is an effective and safe procedure associated with low morbidity and mortality rates. Patients with a high CCI or advanced age should not be discarded for emergent laparoscopic approach. Our results support the choice of ELCBDE as a primary option in the emergency management of choledocholithiasis.

Clinical efficacy of laparoscopic cholecystectomy plus cholangioscopy for the treatment of cholecystolithiasis combined with choledocholithiasis

BACKGROUND

Currently, endoscopic retrograde cholangiopancreatography (ERCP) plus laparoscopic cholecystectomy (LC) is the main treatment for cholecystolithiasis combined with choledocholithiasis. However, the treatment is unsatisfactory, and the development of better therapies is needed.

AIM

To determine the clinical efficacy of LC plus cholangioscopy for cholecystolithiasis combined with choledocholithiasis.

METHODS

Patients (n = 243) with cholecystolithiasis and choledocholithiasis admitted to The Affiliated Haixia Hospital of Huaqiao University (910th Hospital of Joint Logistic Support Force) between January 2019 and December 2023 were included in the study; 111 patients (control group) underwent ERCP + LC and 132 patients (observation group) underwent LC + laparoscopic common bile duct exploration (LCBDE). Surgical success rates, residual stone rates, complications (pancreatitis, hyperamylasemia, biliary tract infection, and bile leakage), surgical indicators [intraoperative blood loss (IBL) and operation time (OT)], recovery indices (postoperative exhaust/defecation time and hospital stay), and serum inflammatory markers [C-reactive protein (CRP), tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6) were compared.

RESULTS

No significant differences in surgical success rates and residual stone rates were detected between the observation and control groups. However, the complication rate, IBL, OT, postoperative exhaust/defecation time, and hospital stays were significantly reduced in the observation group compared with the control group. Furthermore, CRP, TNF-α, and IL-6 Levels after treatment were reduced in the observation group compared with the levels in the control group.

CONCLUSION

These results indicate that LC + LCBDE is safer than ERCP + LC for the treatment of cholecystolithiasis combined with choledocholithiasis. The surgical risks and postoperative complications were lower in the observation group compared with the control group. Thus, patients may recover quickly with less inflammation after LCBDE.

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.