Surgical (open and laparoscopic) Management of large difficult CBD stones after different sessions of endoscopic failure

Abstract

Objectives: For difficult CBD stones that cannot be extracted by ERCP, patients can be managed CBD exploration. The aim of this study was to assess these surgical procedures after endoscopic failure. Methods: We retrospectively analyzed 85 patients underwent surgical management of difficult CBD stones after ERCP failure, in the period from mid 2013 to mid 2018. Results: There was significant correlation between number of ERCP sessions and post ERCP complications (P = 0.001). Impacted large stone was the most frequent cause of ERCP failure (60%). LCBDE and OCBDE were 29.4% (n = 25) and 70.6% (n = 60) respectively. Primary CBD repair, T-tube insertion, HJ and TDS were done in 45.9%, 40%, 8.3% and 5.9% respectively. By comparing LCBDE and OCBDE groups, patient age and hospital stay were significantly lower in laparoscopic group, while, T-tube insertion, choledocoscope use, operative time and post operative bile leak were significantly higher. Furthermore, patients underwent choledocoscope had significant direction to primary CBD repair and lower missed stones rate. While, on comparing T-tube with primary closure of CBD groups, there was significant lower operative time and hospital stay in the later. Conclusion: Difficult CBD stones 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, choledocoscope has a good impact on stone clearance rate with direction towards doing primary repair that is better than T-tube regarding operative time and hospital stay.