Laparoscopic Management of Common Bile Duct Stones

Laparoscopic Management of Common Bile Duct Stones

Mohammed Shaaban Khalifa, MD; Mohamed Ibrahim Hassan, MD.

Department of General Surgery, Faculty of Medicine – Ain Shams University, Cairo, Egypt.

Introduction: Common bile duct(CBD) stones are found in approximately 16% of the patients undergoing laparoscopic cholecystectomy (LC). Till recently, the gold standard for treating CBD stones wasendoscopic removal, if that failed, then open surgery. However, in the laparoscopic era, the besttreatment for CBD stones is a matter of debate and it continues to evolve.

The objective of the presentstudy was to determine whether laparoscopic CBD exploration

(LCBDE) is a safe, feasible and single-stageoption for the management of CBD stones.

Patients and methods: All patients were done in our surgery department. Out of the

450 laparoscopiccholecystectomies between 2012-2015,we did selective intraoperative cholangiogram in 45 patients(10%) who were suspected to have CBD stones based on deranged liver function tests, dilated CBD with orwithout CBD stone on sonography or having the history of recent jaundice/ pancreatitis. If CBD stonewas found, either a transcystic or transcholedochal exploration was done depending on the size, site,number of stones and CBD diameter. Choledochotomy was closed over a t-tube in few numberof patients. Primary closure of CBD was done in the majorityof patients and in one patient we placed an antegradestent and in another one we placed endoscopic stent into the CBD laparoscpically which was removed afterfour weeks.

Results: Till date we have performed LCBDE in 34 patients. Transcystic exploration wasdone in 10 patients and transcholedochal exploration was done in 20 cases out of which

2 patientshad minor biliary leak which settled on conservative treatment in 2-3 days. Four patients requiredconversion to open surgery as there were multiple stones. We did not have any major complication andon 6 months follow-up in 83.3% patients, none was found to have residual stones.

Conclusion: Treatment of CBD stones depends on the resources available, technical limitations and the surgeon’sexpertise. Laparoscopic CBD exploration is a safe, feasible and single-stage option for the managementof CBD stones.

Key words: Laparoscopic surgery, common bile duct (CBD) exploration, selective intraoperative cholangiogram (IOC), choledocholithiasis.

Introduction:

Common bile duct (CBD) stones are found approximatelyin 10-16% of the patients undergoing laparoscopic cholecystectomy (LC).1-4  Until recently, it was generally agreed that if stones are detected in CBD preoperatively, it seemed appropriate to remove  them  prior  to  LC  by  ERCP.  If CBD stonecould not be extracted by RECP, then  CBD  stone  was  extracted  by  open CBD exploration. However, in the present laparoscopic era, the best treatment for patients with choledocholithiasis is a matter of debate and the management of choledocholithiasis continues to evolve.5 If the stones are found by  intraoperative  cholangiography  during LC, the surgeon may either do the LC and refer the patient to ERCP postoperatively, or he may convert to open CBD exploration, or in the current times, he may do LCBDE.

The advent of ERCP and ES dramatically changed the management of CBD stones. ERCP is a quick and often painless procedure, successful in >90% of the patients.6 However, there are few adverse effects of the procedure like pancreatitis, bleeding, failure to clear duct, cholangitis, recurrent stone formation.7

The second revolution in the management of the bile duct stones came with advancement in  the  laparoscopic  surgery.  The  objective of the present study is to determine that laparoscopic CBD exploration is a safe, feasible and single-stage option for the management of CBD stones.

Patients and methods:

A retrospective analysis was done on the patients undergoing LC between January 2012 and April 2015. Thorough history and clinical examination was done and the patient was investigated in the form of routine blood tests, liver function tests including, amylase and abdominal sonography. If there was suspicion of CBD stone,on the basis of predictors of CBD stones as shown in Table (1), patients were subjected to selective Intraoperative cholangiogram(IOC). We have not used any scoring system for predicting the CBD stone. Patients with choledocholithiasis associated with mild gall stone pancreatitis were operated during the same admission if the Ransonʼs score was 3 or less. If the Ranson’s score was >3, surgery was postponed till the acute bout of pancreatitis subsided.

Patients who were unfit for operation or those  with  severe  pancreatitis/  cholangitis, and  those  who  were  diagnosed  to  have CBD stone with bile duct diameter <6 mm were subjected to ERCP and were excluded from the present study. Also patients who had previous upper abdominal surgery were excluded  from  the  present  study.  Patients who had previous ERCP with failure of stone extraction were subjected to LCBDE.

Technique: All operations were done supervised by senior consultants and we kept improving our learning curve to shorten the operation time, decrease complications rate, and transfer the experience to junior staff in our 8B unit.

The standard 4-port configuration for LC was used. A fifth port was made inbetween the right midclavicular and epigastric port just below the subcostal margin for inserting the choledochoscope, 2 mm for transcystic exploration and 5 mm for transcholedochal exploration.

The fundus of the gall bladder was retracted towards the right shoulder and the Hartman’s pouch was retracted downwards and outwards toward the right hip. Dissection began at the neck of the gall bladder and continued  proximally  until  the  junction  of gall bladder with the cystic duct was clearly defined. Dissection was continued proximally on to the cystic duct until there was adequate length   to   perform   cholangiogram.   Then the cystic duct was milked to wardsthe gall bladder to dislodge any cystic duct stone into the gall bladder. A clip was applied on the gall bladder side to prevent any back slippage of gallstone into the CBD and to prevent biliary spillage into the operative field.

IOC was done using a ureteric catheter (4-5 Fr) or an infant feeding tube (no 5-6), which was passed through the cystic duct (after making a small nick in the cystic duct) into the CBD. After the insertion of the catheter, a clip was applied snugly to prevent any back leakage of the contrast medium. Digital C-arm fluoroscopy provided the real time imaging of the biliary tree. In cases where the cystic duct could not be cannulated, contrast was directly injected into the CBD through a lumbar puncture needle (24Fr) percutaneuosly Figure (1).

On cholangiogram, we looked for any filling defect, its size, site, number of bile duct stones, and free passage of contrast into the duodenum and for any anatomical variations of the biliary tree. We selected transcystic or transcholedochal approach to remove CBD stones depending on the factors shown in Table (2).

CBD stones were extracted with the help of Dormia basket /balloon catheter, irrigation/ suctioning or by simply manipulating bile duct using blunt forceps. After retrieving the stones, the cystic duct stump was closed with clips or suture ligature and the gall bladder

A                                                   B

Figure (1): Intraoperative cholangiography (A) Transcystic catheter placement (B) C-arm image after contrast injection.

A                                                 B                                              C

Figure (2): (A) Dissection of Calot trianglefig. (B) Insertion of ureteric catheter. (C) Transcystic

exploration.

A                                                 B                                                 C

Figure (3): (A) Transcholedochal exploration with primary duct closure. (B) Closure over

T-tube. (C) Choledochotomy incision with stone.

Figure (4): Choledochoduodenostomy.

was removed in the usual manner Figure (2).

Transcholedochal        exploration        was performed  in  the  following  manner. After

opening up of the Calot’s triangle, the anterior surface of the CBD was dissected carefully and   choledochotomy   was   performed   by

Table (1): Predictors of CBD stone.

Table (2): Factors influencing approach.7

Table (3): Our experience.

Table (4): Our complications

a longitudinal incision with the help of endoscopic  knife  just  below  the  insertion of the cystic duct into the bile duct. In the initial few cases we used stay suture before performing choledochotomy but later we incised bile duct longitudinally without any stay sutures. The stones were retrieved by spontaneous evacuation while incising the bile duct, blunt instrumental pressure with atraumatic forceps, Dormia basket, Fogarty balloon catheter or irrigation and suction.

Completion cholangiography or choledochoscopy  was  performed  to  assess the completeness of the procedure.

Choledochotomy was closed over t-tube with continuous 3/0 vicryl suture in 3 (10%) of patients Figure (3). We did primary closure of CBD in the majority of cases 15 (50%), after assessing the clearance of the CBD and in one case we placed a trancystic antegrade stent (using 5Fr ureteric catheter) which was brought out via cystic duct. The cystic duct was ligated twice with the antegrade stent in situ using 2/0 vicryl. In another case we placed a modified endobiliary stent (commercially available endobiliary stent, Fr 7 and 9 cm in length, with elimination of the proximal flap on the biliary side) into the distal CBD with distal flange through the papilla into the duodenum with the aid of choledochoscope.

While choledochoduodenstomy have been performed in 2 patients Figure (4).

After bile duct closure, cholecystectomy was performed in the usual manner. We placed an infrahepatic tube drain in all the cases which was usually removed on Day 3-4 post operativelyas the output decreased below 30 ml/day.

Results:

45 patients were subjected to selective IOC due to the suspicion of CBD stones based on the predictors of CBD stones as given in Table (1).8

Out of the 45 patients,35 patients were female and 10 were male. The mean age group of the patients was 42 years (25-68 years). Out of the 45 patients undergoing IOC, CBD stones  were  detected  in  34  cases  (75.6%). Out of 34 cases, 15 cases had a preoperative diagnosis of CBD stones (US)and the rest were picked up on IOC. We removed CBD stones transcystically or by choledochotomy as shown in Table (3).

Median duration of the procedure was 75 min (60-150min). At the beginning of our experiencethedurationwaslonger,particularly in patients undergoing choledochotomy after failed trans-cystic extraction. The time taken for choledochotomy was 30-40 min more than that for the transcystic approach.

Post-operative   course   was   similar   to that of LC in the patients where transcystic exploration was done and the patient was discharged on post-operative Day (POD) 3.

In patients who had undergone transcholedochal approach, t-tube was clamped  on  (POD)  4  and  was  removed on (POD) 7 without routine T-tube cholangiogram. Intra-abdominal drain was removed  as  the  patients  started  oral  diet and the drain output <30 ml/day. All the patients were discharged on (POD) 7, except the 2 patients who had minor biliary leak which settled on conservative management discharged in 2-3 days later on.

In patients where we put antegrade stent, we removed the stent on (POD) 4 and the patient was discharged on day 5.

We placed modified endobiliary stent laparoscopically into the CBD across the duodenum in one patient and the stent was removed after 4 weeks by endoscopy.

We did not have any mortality and the various complications which we encountered during laparoscopic CBD exploration are shown in Table (4).

We had to convert the laparoscopic procedure to conventional open CBD exploration in 4 patients. Out of these, we could not clear the bile duct in 3 patients due to multiple stones and in 1 patient there were severe adhesions present in the Calot’s triangle and the bile duct could not visualized properly. In 2 patients we had minor bile leak after removal of t-tube which settled on conservative treatment in 2-3 days. Minor wound infection in the form of erythema and serous collection at the port site occurred in 2 patients and 1patient had small hematoma at  the  epigastric  port  site  through  which gall bladder was extracted had treated conservatively. Mild pancreatitis developed in 2 patients which resolved on conservative treatment in 2-3 days.

Follow-up after 6 months were completed stone was found. Rest of the patients were lost to follow-up.

Discussion:

The best treatment of choledocholithiasis must be simple, reliable, readily available, cost-effective and patient-friendly. The incidence of CBD stones in patients undergoing LC is 10-16%, so the surgeon must be prepared to manage CBD stones appropriately, depending on whether the diagnosis is made preoperatively or during the surgery.10 If choledocholithiasis is suspected  preoperatively,  recommendations in past were to get an ERCP and if stones were found, ES and extraction of stones.

But there are a few important variables to consider before committing ourselves to this so-called old testimony. Firstly, ERCP is successful in >90% of the patients but it is highly dependent on the availability of an experienced endoscopist to achieve such a high success rate.11 The second consideration is that of cost and the need for a second stage  procedure.12,13   If  a  stent  is  placed then removal needs another endoscopy, usually   after   4   weeks.   The   intervening period requires antibiotics in many cases which further increases the cost factor. Thirdly, there are no selective criteria that can accurately predict the presence of CBD stone.14 Taking into account all the positive predictors     (history,clinical,     biochemical, and sonography) for CBD stones,in most of the series reported in the literature, positive ERCP occurs in only up to 30-35% of the cases.15 On the other hand if we do routine IOC, we detect the stone in about 10% of cases and on selective IOC, CBD stones can be detected in about 25% of the cases.16

Finally, the risk of potential complications of  ERCP  should  be  considered.  Although the complication rate is decreasing with increasing experience, pancreatitis continues to be a problem in most of the reported series, with an incidence of morbidity up to 7% and mortality  of  0.2-2.3%.17  The  sphincter  of Oddi (SOD) provides a barrier that prevents increases duodenal reflux and a higher rate of bactibilia (60%) with the increasing rate of recurrent biliary stone formation.19

This  duodeno-biliary  reflux  further causes biliary epithelium to adapt to a new environment. Chronic bactibilia, in addition to pancreatic reflux (which is proved to be responsible for higher rates of malignancy in case of congenital choledochal cyst, may lead to neoplastic changes in the biliary epithelium.20,21

LCBDE has considerable advantages for treating both gall bladder and bile duct stones in a single stage without any preoperative examination to detect the presence of stones in CBD.22,23 The main drawback of LCBDE is  the  increased  operative  time  and  the cost involved, particularly with the use of choledochoscope.

There is a possibility of false positive cholangiograms in open procedure but did not encounter this problem. LCBDE is successful in 75-95% of the patients and is comparable to the endoscopic treatment. Moreover,if the endoscopic treatment fails, particularly inthe postoperative  setting,  this  may  require  a third stage open procedure. While if LCBDE fails, one can convert at the same time. Also as the experience is increasing in LCBDE, the success rate will further improve. (Liebermann et al), and (Martin et al); found that the single stage procedure had significant lower morbidity and shorter hospital stay resulting in lower cost than those of staged ERCP and LC.24,25

In our study, patients who were unfit for operation orthose with severe pancreatitis/ cholangitis or with previous upper abdominal surgery or with CBD stone but bile duct dilatation  <6  mm  subjected  to  ERCP and were excluded from the current study. We have deliberately not done ERCP in the study group  patients  considering  the  cost,  two- stage procedure, risk of complications and the possibility of failure.

Certainly, ERCP has been an important modality  for  treating  leftover  CBD  stone after LC. The current trend is to utilize ERCP Various randomized controlled studies comparing the two-stage (ERCP with LC) procedure and one-stage LC with LCBDE, showed that the one-stage procedure resulted in a shorter stay and similar stone clearance rates.26,27

Transcystic CBD exploration is preferred as it is easy, more physiological, associated with  less  complications,  does  not  require t-tube placement and intra-corporeal suturing and  the  post-operative  course  is  almost similar to patients undergoing LC alone. However,  a  transcholedochal  approach  is a  must  if  there  are—multiple  stone  (>5), stone >6 mm, proximal stone, CBDsize <6 mm, cystic duct size <4 mm (too narrow to pass choledochoscope), and if there is any anatomical variation of the biliary tree.28

Traditionally, CBD exploration is accompanied by t-tube drainage of CBD. Nevertheless, there are a few disadvantages, inconvenience, and discomfort, delayed recovery, longer stay, risk of tube displacement, risk of infection and rarely, fracture of tube fragment, and retention in the CBD.28

Lange et al; first reported laparoscopic CBD  primary  closure  with  antegrade stent.29 Recently, many studies have shown feasibility and potential advantages of antegrade stent which include decompression of CBD postoperatively, facilitation of ERCP cannulation postoperatively and early return to full activity.30

Nowadays the combined laparo- endoscopic approach to CBD stone is talked about in which a modified plastic biliary stent is used (modified by breaking the proximal flange).8 Potential problems with the plastic stent are bile leak, stent occlusion, early stent migration and the need of future endoscopy for the removal of the stent.31,32

Out of 45 patients we found CBD stones in 34 patients. We were able to successfully remove stones in 30 patients and in 4 patients, we had to convert to open CBD exploration as we were not able to remove completely all the stones laparoscopically.

Now  we  have  every  confidence in  the technique  of  LCBDE,  our  success  rate  is there was no major complication, and in follow-up, no residual stone was found. Our operating time is also decreasing as all the team members are getting familiarized with the  technique  and  equipments.  Although we still rely on ERCP and ES for high risk patients or those who are unfit for operation or those with severe pancreatitis/ cholangitis or those who are diagnosed as to have CBD stone with bile duct diameter <6 mm.

Our results are good and improving; we need time and more efforts to be comparable to the published data in the literature ,in terms of  stone  clearance,  minimal  complications, a shorter hospital stay, and rapid recovery time.33,34 The optimal management of choledocholithiasis remains unclear in the present  laparoscopic  era.  Management  at a  single  stage  is  the  optimal  approach  in terms  of  safety,  patient  satisfaction  and cost-effectiveness.

Conclusion:

CBD     stones     are     associated     with about 10-16% of the patients undergoing cholecystectomy. Treatment algorithms have changed for CBD stones with the advent of endoscopic management which is now getting further modified with the advancement in laparoscopic surgery.

The treatment of CBD stones depends on the resources available, technical limitations, and the surgeon’s expertise. Laparoscopic CBD  exploration  is  a  safe,  feasible  and single-stage option for the management of CBD stones. In spite of its difficulty and learning curve is slow and demanding, it is improving in our department 8B unit, more data and time are needed to improve our technique and outcome.

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