The role and designation of emergency choledochoscopy in the laparoscopic treatment of patients with complicated choledocholithiasis

Abstract

Background. The management of patients with cholelithiasis (gallstone disease) and choledocholithiasis who require removal of the gallbladder remains debatable and require urgent actions of the surgeon, especially in cases with concomitant mechanical jaundice. Laparoscopic choledochoscopy is an effective method of examining the bile ducts that allows for the complete removal of calculi, but in the meanwhile, there is not enough information about its effectiveness and sensitivity as part of surgical technology. Purpose: to improve the outcomes of treatment in patients with choledocholithiasis using laparoscopic choledocholithoextraction and choledochoscopy, as well as to assess the diagnostic value of laparoscopic choledochoscopy in bile duct examination and its significance as a component of surgical technology in laparoscopic choledocholithoextraction in patients with gallstone disease. Materials and methods. Between 2018 and 2024, we conducted an analysis of treatment outcomes in 139 patients with gallstone disease and choledocholithiasis, 51 males (36.7 %) and 88 females (63.3 %). The mean age of patients aged 17 to 86 years was 59.5 ± 1.7 years: males — 56.9 ± 1.7 years, females — 62.1 ± 1.7 years. All participants underwent laparoscopic choledocholithoextraction with choledochoscopy. In 29 (20.8 %) patients, choledocholithoextraction and choledochoscopy were performed through the cystic duct, the remaining 110 (79.1 %) people underwent choledocholithotomy with lithoextraction via choledochoscopy. Surgical intervention (laparoscopic choledocholithoextraction and choledochoscopy) was performed using a choledochofiberscope Olympus CHF-V with a diameter of 5 mm and a Karl Storz with a diameter of 3 mm; lithoextraction was done via choledochotomy access with the use of Dormia-type baskets (FG-55D, FG-55D Olympus). Results. All patients underwent bile duct examination via choledochoscopy with mechanical choledocholithoextraction. The first group included 110 (79.1 %) participants who had laparoscopic choledocholithotomy, lithoextraction and choledochoscopy. The second group comprised 29 (20.8 %) patients who underwent choledocholithoextraction and choledochoscopy through the cystic duct. In the first group, on average 3.4 ± 0.4 stones (from 1 to 24) were removed, in the second group — 2.6 ± 0.5 (from 0 to 6). During laparoscopic choledochoscopy with lithoextraction in the first group, bile duct clearance rate amounted to 108 (98.1 %), in the second group — 27 (93.0 %). Bile leakage through the drainage was recorded in 4 (4.5 %) patients from the first group. Endoscopic papillosphincterotomy with lithoextraction was performed in 2 (1.8 %) patients from the first group and 2 (6.8 %) from the second group, due to wedged stones that could not be removed. There were no fatal cases observed. Conclusions. Urgent laparoscopic choledocholithoextraction with choledochoscopy should be applied as one of the technologies for the treatment of gallstone disease and choledocholithiasis, which makes it possible to perform choledocholithoextraction, choledochoscopy with cholecystectomy in one step, while preserving the autonomy of the hepatopancreatobiliary zone and avoiding complications typical for transpapillary interventions.