Abstract
Background. The management of choledocholithiasis has evolved from open common bile duct exploration (OCBDE) to therapeutic endoscopic retrograde cholangiopancreatography (ERCP) to laparoscopic common bile duct exploration (LCBDE). Each entails a degree of difficulty. Aim. To review 5-year results of bile duct exploration in an UGI unit. Methods. Common bile duct explorations (CBDEs) performed between January 2008 and January 2013 were identified from a prospectively collected clinical audit system and results reviewed retrospectively. Results. 216 CBDEs were performed, 119 (55%) as an emergency and 52 (24%) following failed ERCP. Open CBDE (OCBDE) was performed primarily in 34/216 (16%) patients and attempted laparoscopically in 182 (84%). Fifty nine (32%) Laparoscopic CBDEs (LCBDEs) were converted to OCBDE. Of the remaining 123 LCBDEs, 51 (41%) primary choledochotomies and 72 (59%) primary transcystic CBDEs (TC-CBDEs) were performed. Forty nine (68%) TC-CBDEs were considered successful and 23 (32%) failed. Fifteen failed TC-CBDEs were converted to a successful laparoscopic choledochotomy. Ductal clearance was achieved in 187/216 (87%) patients and retained stones were identified in 20/123 (16%) LCBDEs. Complications occurred in 52/216 (24%) patients. There were 8/216 (4%) bile leaks requiring further intervention. Postoperative ERCP was carried out in 32/216 (15%) patients and 9/216 (4%) required relaparoscopy/laparotomy. No patient died. Conclusions. Successful management of choledocholithiasis requires a breadth of laparoscopic and endoscopic expertise.
Highlights
The management of concomitant gall bladder and common bile duct (CBD) stones has evolved significantly over the past 20 to 30 years
Following the introduction of laparoscopic cholecystectomy (LC) [1] there has been a gradual increase in Laparoscopic Common bile duct explorations (CBDEs) (LCBDE) which has been shown by a few enthusiasts to be as effective at CBD clearance and associated with reduced hospital stay compared to preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by LC [2,3,4,5]
In the remaining 32 patients CBD stones were detected by intraoperative cholangiography (IOC)
Summary
The management of concomitant gall bladder and common bile duct (CBD) stones has evolved significantly over the past 20 to 30 years. LCBDE, either using the transcystic route (TC-LCBDE) or via a choledochotomy, does involve more advanced laparoscopic skills, often including flexible choledochoscopy, and as a result the default procedure in many hospitals remains to be ERCP either before or after laparoscopic cholecystectomy. Such is the reliance upon ERCP that in some centres surgery for CBD stones is considered a lost art [6]. The management of choledocholithiasis has evolved from open common bile duct exploration (OCBDE) to therapeutic endoscopic retrograde cholangiopancreatography (ERCP) to laparoscopic common bile duct exploration (LCBDE). Successful management of choledocholithiasis requires a breadth of laparoscopic and endoscopic expertise
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