Role of Flexible choledochoscopy in present era – for difficult billiary stones.

Abstract

Introduction: Several studies have concluded that Laparoscopic Common bile duct exploration (LCBDE) procedures are superior to sequential endo-laparoscopic treatment in terms of both clinical and economical outcomes. Method: In all the cases of LCBDE Calot’s triangle was dissected and cystic duct & artery were clipped before Laparoscopic CBD exploration (Intra-operative Flexible choledochoscopy was done with help of a Olympus (6mm) Flexible Choledochoscope (CYF-5A) via Choledochotomy approach rather than transcystic appreoach). After removal of CBD stones with dormia basket, irrigation & ballon sweep, check completion choledochoscopy of both lower CBD & CHD was performed in all the cases. CBD was closed primarily in all the LCBDE cases over a stent in situ (Infant feeding tube No-7/8). Result: A total of 82 patients underwent LCBDE and 8 patients underwent open CBD exploration (criteria dilated CBDE >20mm with intrahepatic stones) between the periods of 2011 to 2018. Age of the patients ranged from 22 to 76 years. The mean age is about 42.30 years. Peroperatively 14(17.07%) cases had only choledocholithiasis (had previous history of cholecystectomy), 52(63.41%) cases had cholelithiasis with choledocholithiasis, 12(14.63%) cases had associated hepatolithiasis and 2(0.024%) cases had retained cystic duct stump stones with choledocholithiasis. Of eight open CBD exploration patients five and three patients underwent choledochoduodenostomy and Roux-en-Y hepaticojejunostomy respectively. In this series Mechanical lithotripsy with a rigid scope was used in 18 patients after failure to remove large stones by instrumental exploration and percentage of residual stone in this study was 0%. Two cases of LCBDE was converted to open procedure (due to presence of large impacted intrahepatic stones in one case and difficulty in defining Calot’s triangle in another case). Conclusion: Examination of the bile ducts under direct vision with a choledochoscope seems a certain method of ensuring that there are no residual stones.