Laparoscopic transcystic common bile duct exploration in the management of choledocholithiasis

Laparoscopic transcystic common bile duct exploration in the management of choledocholithiasis

Moustafa  B. Mohamed, MD; Osama H. Gharib, MD; wesam M. Amr, MD; Ashraf Goda, MD

General Surgery Department,  Zagazig University,  Zagazig, Egypt.

Background: Common bile duct (CBD) stones are identified in 10-15% of patients undergoing surgery for symptomatic cholelithiasis. When choledocholithiasis is suspected preoperatively, it is recommended that endoscopic retrograde cholangiography  (ERC) be performed, and if the choledocholithiasis  is confirmed, the patient should then undergo endoscopic sphincterotomy (ES). When CBD stones are discovered intraoperatively, the surgeon proceeds with laparoscopic common bile duct exploration (LCBDE), converts the case to open CBD exploration and choledocholithotomy,  or leaves the stones in place for postoperative ES and stone extraction. We report here our initial results oflaparoscopic transcystic CBD exploration (LTCBDE) in the management of patients with choledocholithiasis.

Patients and methods: From October  2009 to June 2012, we performed 320 laparoscopic cholecystectomies  for symptomatic  gallstone disease at Zagazig University Hospitals.   In the present study, intraoperative  cholangiography  (IOC) was performed in 47 out of 320 (14.7%) patients. It was negative in 5 (10.6%)  patients and suggestive ofCBD stones in 42 (89.4%) patients. The incidence of choledocholithiasis in our study was 13.12% (42 from 320 patients). Three patients were converted to open surgery directly when CBD stones were detected, and two patients were referred for postoperative ERCP.  Laparoscopic CBD exploration (LCBDE) was attempted in 37 patients. In 7 patients laparoscopic choledochotomy  was done. In the remaining 30 patients (71.4%) LTCBDE was performed.

Results: LTCBDE was successful in 27 out of 30 patients (90%). In three patients, LTCBDE failed  and  were converted  to  open  surgery. Causes  of  failure of  TCBDE  were  numerous stones (> 8) in one patient, impacted stones at distal CBD in another patient and intrahepatic displacement  of stones in the third patient. The mean operative time was 110 ± 30 minutes. Postoperative  complications included pulmonary atelectasis in two elderly patients, deep vein thrombosis in one patient and ileus in one patient. The overall complication  rate was 13.3%. There were no deaths. No bile leak was observed in any of our patients and all were discharged within the first 48 hours. The mean recovery time was 8 days (ranging from 7 to 10 days). Time to return to full physical activity was 14±4 days.Fallow-up for 6 months to 2 years was possible in 26 patients (86.7%), and no residual stones were found in any ofthem.

Conclusion: CBD  stones still occur in about 10-15% ofpatients undergoing LC. 90% of these patients could be treated successfully using LTCBDE,  with no increase in morbidity or mortality; it seems reasonable to remove stones during the laparoscopic procedure to avoid the possibility of postoperative ERCP or conversion to open surgery. The complications, length of hospital stay, and recovery time were similar to outcomes in patients who underwent LC only. We found that  multiple or impacted  stones  are risk factors  for conversion to open surgery. The benefits attained by minimally invasive surgery confirm that LTCBDE should become the primary strategy in the vast majority of patients harboring common bile duct stones.

Key words: Laparoscopic cholecystectomy, common bile duct stones, laparoscopic common bile duct exploration.

Introduction:

Laparoscopic      cholecystectomy      (LC) has  become  the  gold  standard  for the treatment of symptomatic cholelithiasis and cholecystitis.! Common bile duct (CBD) stones are identified in 10 to 15 percent of patients undergoing surgery for symptomatic cholelithiasis. CBD stones require extraction to avoid complications, such as acute suppurative cholangitis, obstructive jaundice, hepatic abscess, and acute pancreatitis) Prior to the development  of LC, the management of these patients was CBD exploration at the time   of  cholecystectomy.3  Clearance  rates of ± 90% were  accepted  as the standard  of care. Endoscopic retrograde cholangiography (ERC), with or without sphincterotomy and stone  removal  (ERC  ± ES), was  employed only in cases where cholangitis was present preoperatively, or where patients were not considered candidates for general anesthesia, or where CBD stones were discovered postoperatively.4-6

Until  recently   it  was  generally   agreed that  if stones were  detected  in the CBD  on preoperative   imaging   studies,   or   if  they were  suspected   on  the  basis  of  abnormal liver function tests, it seemed reasonable to remove the stones prior to  cholecystectomy by  ERC   ± ES.7    Although  ERC  plus  ES allows   successful   removal   of   more  than

90%  of CBD stones, consideration  must be

given to the extra expense and the potential complications associated with this procedure. Even in the hands of experienced  surgeons, the rate of complications is reported to be in the range of 4% to 6%. These complications may   include   acute   pancreatitis,   bleeding, perforation,  and  cholangitis.8  These  factors and   the   laparoscopist   desire   to   achieve the  level  of  surgical  success  in  managing choledocholithiasis  that                   existed in                                   the prelaparoscopic  era  led to the  development of   new   laparoscopic   techniques   of   CBD exploration.9 Both transcystic (via the cystic duct)  and transductal  (via  choledochotomy) approaches      were              developed.                   The characteristics   of   the   transcystic   method proved  to  be  consistent  with  the  goals  of laparoscopic   approach:  minimal  morbidity,

no T-tube, no drain, and a rapid return to normal activity in most cases. The transductal approach proved useful in cases where large stones, intrahepatic stones, or a small friable cystic duct precluded the use of the transcystic method.  The  latter  approach,  however, required the acquisition of suturing and knot­ tying skills not necessary in the transcystic method. 1 We report  here  our  initial  results of laparoscopic transcystic CDB exploration (LTCBDE) in the management of patients with choledocholithiasis in terms of successful stone removal, operative time, morbidity and mortality, and length ofhospital stay.

Patients and methods:

From    October    2009    to    June    2012, we performed 320 laparoscopic cholecystectomies  for symptomatic  gallstone disease at Zagazig University Hospitals. Our patients   included   240  women   (75%)   and

80 men (25%). Median age was 45.6 years (range 23-72 years). All patients underwent preoperative abdominal ultrasound imaging, liver function tests, and they were also asked about any history of jaundice or pancreatitis. On the basis of elevated bilirubin, gama­ glutamyltransferase (GGT) and alkaline phosphatase  levels, a history  of pancreatitis or jaundice, or the presence of a dilated common bile duct or common bile duct stones on preoperative ultrasound examination, selective cholangiography was performed. These  were  all  considered  risk  factors  for CBD stones Table (1).

For           laparoscopic           intraoperative

cholangiography  (IOC),  a clip  was  applied proximally  across  the  cystic  duct  once  it was well  dissected.  An  incomplete  vertical ductotomy   was   created,   taking   care   not to  injure  the  posterior  wall  of  the  duct.  A cholangiogram   catheter  (4  to  5  F)  with  a metal  reinforced  tip  was  inserted  into  the abdomen through a transabdominal14-gauge angiocatheter that has been placed in the right upper quadrant. The catheter was manipulated into   the      cystic                   duct       with    laparoscopic instruments. A clip or a cholangiogram clamp was loosely applied around the duct with the catheter.  Placement  of  a  hydrophilic  guide

wire through the cholangiogram catheter facilitates  placement of instruments for CBD stone extraction  and dilatation  of the cystic duct with balloon catheters or mechanical dilators if necessary.

Findings   on   cholangiography   that   are

suggestive of CBD stones include dilated bile ducts, filling defects, or failure of contrast flow into the duodenum  Figure (1). In the present

study, roc was performed  in 47 patients. It

was negative  in 5 patients and suggestive  of CBD  stones  in  42  patients.  Three  patients were converted to open surgery directly when CBD stones were detected, and two patients were  referred  for   postoperative   ERCP.  A laparoscopic CBD   exploration   (LCBDE) was  attempted  in 37 patients.  In 7 patients laparoscopic            choledochotomy          was       done. Laparoscopic   transcystic   CBD  exploration (LTCBDE)  was attempted  in the  remaining

30 patients. Patients with large (>8mm), numerous  (>  8)  or intrahepatic  stones  and those with small friable cystic duct were excluded from LTCBDE.

When IOC revealed  CBD stones, a fifth trocar with a long intraabdominal sheath was placed high and laterally under the right costal margin to get axial access to the cystic duct. A guide wire was placed through the cystic duct into the CBD. To facilitate passage, the incision  in the  cystic  duct  was made  close to the  CBD. A balloon catheter  was placed over the guide wire to dilate the cystic duct, if necessary. Using the same guide wire a flexible bidirectional choledochoscope with working channel was introduced. Saline was flushed through the scope using a pressure irrigation device. When the first stone was identified, a four-wire, 2.4-Fr basket was inserted  down the working  channel, passed just  beyond  the  stone,  opened,  withdrawn, and closed, capturing the stone Figure (2,3). The   stone   and   basket   assemblage   then was pulled up to the tip of the scope and withdrawn together. Choledochoscopy was continued until no stones were identified and the ampulla could be seen, but not necessarily transgressed. Care was taken to extract stones in the right order and  thereby  preventing  a more  peripherally  placed  stone to  whirl  up

into an intrahepatic position. When impacted stones were found a balloon, was used to free them but removal was preferably done with the basket. Small stones and fragments of stones were flushed into the duodenum after intravenous administration of glucagon. An intrahepatic choledochoscopy was performed when it was possible depending on the angle in which the cystic duct entered the common bile duct. A completion  cholangiogram  was obtained to ensure that no stones were left Figure (4). The cystic duct was secured with double endoloops or with two clips.

Results:

In the present study, IOC was performed in 47 out of 320 (14.7%) patients. It was negative in 5 (10.6%) patients and suggestive of CBD stones in 42 (89.4%) patients. The incidence of choledocholithiasis  in our study was 13.12% (42 from 320 patients). Three patients   were   converted   to   open  surgery directly when CBD stones were detected, and two patients were referred for postoperative ERCP. A laparoscopic  CBD exploration (LCBDE) was attempted in 37 patients. In 7 patients laparoscopic choledochotomy was done. In the remaining 30 patients (71.4%) LTCBDE was performed. It was successful in

27 patients (90%). In three patients, LTCBDE failed and were converted to open surgery. Causes of failure of TCBDE were numerous stones(> 8) in one patient, impacted stones at distal CBD in another patient and intrahepatic displacement of stones in the third patient Table (2).

The mean operative time was 110 ±30 minutes.  Postoperative  complications included    pulmonary    atelectasis    in   two elderly patients, deep vein thrombosis in one patient and ileus in one patient. The overall complication rate was 13.3%. There were no deaths. No bile leak was observed in any of our patients  and all were  discharged  within the first  48 hours.  The mean  recovery time was 8 days (ranging from 7 to 10 days). Time to return to full physical activity was 14 ± 4 days.  Follow-up  for  6  months  to  2  years was possible in 26 patients (86.7%) and no residual  stones  were found  in any of them.

These  results  were shown in Table(3).

Discussion:

Choledocholithiasis is found in 10-15% of patients   who  present   for  cholecystectomy. 2

Definitive treatment of these patients includes not only cholecystectomy, but also clearance ofthe entire duct system. The best treatment of choledocholithiasis must  be simple,  reliable,

readily  available, and cost-effective. 1

When choledocholithiasis is suspected preoperatively, it is recommended that ERCP be performed, and  if the  choledocholithiasis is confirmed, the patient should then undergo ES.lO However, there  are important variables to consider: first, ES allows successful removal of more than 90% of common bile duct stones in most series,  but depends on the availability of  an  experienced  and  skilled   endoscopist with  a high  success  rate in achieving biliary cannulation and stone extraction. Another consideration  is  its   high   cost.ll    ERCP   is a procedure with  potential   complications. Acute   pancreatitis occurs   in  approximately

6%   of   patients   who   undergo   ERCP,   and when  sphincterotomy for  stone  extraction  is performed, another  4% of patients  will have additional complications including bleeding, perforation, and cholangitis. 8 Another issue is the potential  risk of delayed stricture  at the sphincter, which  is  something to  be  aware of in the long-term follow-up of younger patients.l2,13

In the early days of laparoscopic cholecystectomy, ERCP  plus ES was usually recommended for  any  patient  who  had jaundice, recent pancreatitis, or a dilated bile duct on ultrasonography, but this approach led to a high incidence of normal  ERCP findings ranging  from  40%  to  70%.7 At the  present time,  these  indicators  are  considered minor risk factors  for the presence  of common bile duct stones  in most patients.ll

When CBD stones are discovered intraoperatively, the surgeon  either  proceeds with   LCBDE,  converts   the   case   to   open CBD  exploration and  choledocholithotomy, or leaves  the stones  in place  for  subsequent ERC ± ES_5,14,15 Although any one of these alternatives  is   acceptable,  the   latter   two

are more costly  and are associated with increased  morbidity.   It would   seem   wise in most  situations, therefore, to  attempt LCBDE  unless  the  patient's  condition demands  termination  of  the   anesthetic  as soon  as possible.  If LCBDE  is unsuccessful or not attempted, then the decision  regarding conversion to  open  CBD  exploration vs. postoperative ERC ± ES will depend  on the local availability of expert endoscopists.l

In our series of 320 laparoscopic cholecystectomies,  we   found    42   patients with  stones   in  the  common   bile  duct,  for an  incidence  of  13.1%.   All  of  them   were

diagnosed during roc, which was performed

selectively in 47 patients. Three patients  were converted to open CBD exploration, and two were referred for postoperative ERCP, with successful stone removal  on all five patients. In  7  patients  laparoscopic  choledochotomy was  done.  In the remaining 30 patients (71.4%) with CBD stones,  LTCBDE was performed. It was  successful in  27  patients (90%).  We found  that  multiple  CBD  stones (>8), intrahepatic displacement of stones,  and stones impacted at the ampulla are risk factors for  conversion. Three  patients  (10%)  had  to be converted because of these risk factors.

Mean operative time was 110 ± 30 minutes. The  overall   complication  rate  was   13.3%, and  was  related  to  pulmonary  atelectasis in two  elderly   patients,   deep  vein  thrombosis in one patient  and postoperative ileus in one patient.  There  were  no  deaths.  All  patients were   discharged  from   the   hospital   within the first 48 hours. We did not observe  biliary fistulas in our patients, and this was attributed to secure clipping/ligation of the cystic stump in  all  cases.  Recovery  time  was  the  same as in patients who underwent laparoscopic cholecystectomy only, and ranged  from  7 to

10 days.

We have  adopted  the  transcystic laparoscopic  approach   as  the  pnmary strategy for treating CBD  stones found intraoperatively.   Although   we    still    rely on postoperative ERCP ±ES for high-risk patients, or patients with multiple  stones  who are not suitable for the transcystic extraction. Patients  with  multiple   stones,  large  stones,

Figure  (1):   Intraoperative  cholangiogram showing a distal CBD stone.

Figure (3): 4-wire basket introduced through the choledochoscope to capture stone.

Table 1: Risk factors for CBD stones

Figure  (2):  CBD  stone  as  seen  through choledochoscope.

Figure (4): Completion cholangiogram.

or stones  in the  hepatic  ducts  were treated by laparoscopic choledochotomy to avoid conversion. Open CBD exploration should be rarely needed at the present time. Our results

are similar to those repmted  by Ottega et al

2003, Lyass and Phillip 2006 and Strombetg et al 2008 in tenns of success of stone removal, minimal complications, a shmt hospital stay,

Table 2: Results of LTCBDE in the present study.

Table 3:  Operative time, hospital stay, and outcomesafter LTCBDE.

and rapid recovery  time.11,16, 17

The optimal  management of choledocholithiasis remains  unclear  in the present  laparoscopic era, but we encourage more surgeons  to be trained  in this technique because  we are convinced  that  most patients with  stones  in the  common bile duct can  be managed  by this gentle  technique with good results.  Management in one session  is the optimal  approach  in terms of safety, patient satisfaction, and cost-effectiveness. It is now time to return the management of CBD stones to the surgeons  as the standard of care m "minimally invasive treatments".

Conclusion

CBD stones still occur in about 10-15% of patients undergoing LC. 90% of these patients could be treated successfully using LTCBDE, with no increase  in morbidity  or mortality; it seems reasonable to remove stones during the laparoscopic procedure to avoid the possibility of   postoperative  ERCP   or   conversion  to open surgery. The complications, length of hospital  stay, and recovery  time were similar to  outcomes in patients  who  underwent LC only.  We  found   that  multiple   or  impacted stones  are risk factors  for conversion to open surgery. The benefits attained by minimally invasive    surgery    confirm   that    LTCBDE should   become  the  primary   strategy in the

vast  majority of  patients harboring common bile duct  stones.

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