Abstract
ObjectivesFor complicated common bile duct stones (CBDS) that cannot be extracted by endoscopic retrograde cholangiopancreatography (ERCP), management can be safely by open or laparoscopic CBD exploration (CBDE). The study aimed to assess these surgical procedures after endoscopic failure.MethodsWe analyzed 85 patients underwent surgical management of difficult CBDS after ERCP failure, in the period from 2013 to 2018.ResultsSixty-seven (78.8%) and 18(21.2%) of our patients underwent single and multiple ERCP sessions respectively. An impacted large stone was the most frequent cause of ERCP failure (60%). Laparoscopic CBDE(LCBDE), open CBDE(OCBDE) and the converted cases were 24.7% (n = 21), 70.6% (n = 60), and 4.7% (n = 4) respectively. Stone clearance rate post LCBDE and OCBDE reached 95.2% and 95% respectively, Eleven (12.9%) of our patients had postoperative complications without mortality. By comparing LCBDE and OCBDE; there was a significant association between the former and longer operative time. On comparing, T-tube and 1ry CBD closure in both OCBDE and LCBDE, there was significantly longer operative time, and post-operative hospital stays in the former. Furthermore, in OCBDE group, choledocoscopy had an independent direction to 1ry CBD repair and significant association with higher stone clearance rate, shorter operative time, and post-operative hospital stay.ConclusionLarge difficult CBDS can be managed either by open surgery or laparoscopically with acceptable comparable outcomes with no need for multiple ERCP sessions due to their related morbidities; furthermore, Open choledocoscopy has a good impact on stone clearance rate with direction towards doing primary repair that is better than T-tube regarding operative time and post-operative hospital stay.
Highlights
The incidence of common bile duct stones (CBDS) in patients with symptomatic cholelithiasis varies widely in the literature between 5% and 33% according to age [1,2,3,4,5]
One hundred patients underwent surgical management of large difficult CBDS after endoscopic retrograde cholangiopancreatography (ERCP) failure, in the period from the beginning of 2013 to the beginning of 2018 in the department of hepato-pancreatobiliary (HPB) surgery, National Liver Institute (NLI), University of Menoufia, Menoufia, Egypt, our study included 85 patients after exclusion of cases with data loss, those who did not complete the follow-up and who refused researches. We did this cohort study which is a single-institution retrospective analysis of a prospectively collected database that assessed these surgical procedures of CBD exploration (CBDE) after endoscopic failure in the period from the beginning of 2013 to mid 2018, where patients were observed from POD1 until the end of June 2018 with a median follow up period of 39 ms, range (6–66 ms)
ERCP followed by LC for managing concomitant gallbladder and CBDS is currently the preferred method in the majority of hospitals worldwide [2]
Summary
The incidence of common bile duct stones (CBDS) in patients with symptomatic cholelithiasis varies widely in the literature between 5% and 33% according to age [1,2,3,4,5]. [8,9,10,11] Different modalities for successful treatment of these stones have been reported after advances in minimally invasive techniques as endoscopy, and laparoscopy, the optimal treatment is controversial [8,12,13]. They include one- or two-stage procedures; the two-stage procedures involve pre- or post- laparoscopic cholecystectomy- ERCP (LC-ERCP), while the singlestage procedures refer to Open or Laparoscopic CBD exploration (OCBDE or LCBDE) [2,10,14,15,16]. Pre- or postoperative ERCP is a popular treatment option commonly performed by endoscopists, List of abbreviations
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