Laparoscopic Bile Duct Exploration Research Articles

Ultrasound Diagnosis of Asymptomatic Choledochal Lithiasis. Case Report

Choledochal lithiasis can be suspected in some cases due to the presence of micro calculi (<5mm) in the gallbladder, long-standing gallstones or advanced age of the patient, with about 5% having "unsuspected choledochal lithiasis". In some cases, it presents only as biliary colic, and choledochal lithiasis is an incidental finding on imaging studies or during cholecystectomy. Ultrasound is the most widely used initial imaging method, it has high specificity (95%), but low sensitivity (25-30%), so in some cases other imaging methods are required to confirm the diagnosis, such as cholangioresonance or intraoperative cholangiography. Treatment allows ERCP on the one hand followed by laparoscopic cholecystectomy or bile duct exploration during laparoscopy. Male, 60 years old, with biliary colic, no history of jaundice, normal blood count, normal bilirubin, slight elevation of alkaline phosphatase, and normal amylasemia. The ultrasound shows images of gallstones and 4mm and 5mm lithiasis images in the distal third of the common bile duct of normal caliber (5mm). Cholangioresonance confirms the finding. It is performed by ERCP extraction of two 7 mm stones, with clear bile drainage to the papillotomy. At 48 hours laparoscopic cholecystectomy without problems. Hospital discharge 24 hours later in good clinical condition. Ultrasound is a valuable diagnostic method in patients with unsuspected asymptomatic choledochal lithiasis. Regarding treatment, there is still no consensus on the best strategy and when choosing it is advisable to take into account accessible resources and that it be an effective treatment.

O-BN06 A Proposed Difficulty Grading System for Laparoscopic Bile Duct Exploration. Benefits to Practice and Research

Abstract Background A gap remains between the mounting evidence for single session management of bile duct stones and the obstacles to wider adoption of this approach. The practice of laparoscopic bile duct exploration (LCBDE) is limited not only by the availability of training opportunities and adequate equipment but also by the perception that the technique is difficult and requires a high skill-set. The aim of this analysis is to compare the preoperative and operative characteristics and the postoperative outcomes in easy vs. difficult LCBDE in a large consecutive series, according to a proposed 5 grade classification. Methods 1326 LCBDEs were graded according to the location, number and size of ductal stones, retrieval techniques used, utilisation of choledochoscopy and specific biliary pathologies encountered. The cohort was divided into two groups: easy (Grades I A&amp;B, and Grade II A&amp;B, requiring transcystic or transductal exploration for up to 15 stones the largest being 15mm) and difficult (Grades III A&amp;B, for over 15 stones or intrahepatic stones of any size needing transcystic choledochoscopy, IV and V with Mirizzi Syndrome, impacted stones, and ducts needing stenting, conversion or bilioenteric anastomosis). Various outcome parameters were compared. Results Age, sex, obesity and previous biliary admissions had no effect on operative difficulty. Emergency admission, obstructive jaundice, previous ERCP and dilated CBD were predictive of difficult explorations. 78.3% of patients with acute cholecystitis or pancreatitis, 37 % of jaundice and 46% of cholangitis had easy explorations. Transcystic stone retrieval was possible in 77.7% of easy explorations and choledochotomy required in 62.3% of difficult explorations (vs. 33.6% in the whole series). Choledochoscopy was utilised in 23.4% of Grades I&amp;II vs. 98% in difficult explorations. As expected more biliary drains, stenting, bilio-enteric anastomosis, conversions, operative time, biliary-related complications, hospital stay, readmissions and retained stones increased with difficulty. Grades I&amp;II patients had 2 or more hospital episodes in 26.5% vs. 41.2% for grades III to V, the median presentation to resolution interval increasing from 1 to 3 weeks. There were 2 deaths in difficulty Grade V and one in Grade IIB. Conclusions Difficulty grading of LCBDE is a useful tool of predicting outcomes. It facilitates comparison between studies and fair assessment of training. LCBDEs are easy in 72% and of these 77% can be completed transcystically. It is hoped this will encourage more units to adopt single session management of bile duct stones through establishing referral protocols, developing and refining the skills through training and acquiring the necessary equipment.

LAPROSCOPIC COMMON BILE DUCT EXPLORATION: STENT DRAINAGE VERSUS T- TUBE DRAINAGE

Introduction: One of the safe &amp; feasible methods for the management of extra-hepatic bile duct calculi is laparoscopic bile duct exploration. Around 10-15% of the subjects who have surgery due to gallstone disease have choledocholithiasis associated with it. A standard procedure to prevent bile escape from the choledochotomy site is conventionally postoperative T-tube drainage following common bile duct exploration. &#x0D; Aims &amp; Objectives: Comparative study of laproscopic common bile duct exploration using stent drainage versus t- tube drainage.&#x0D; Material &amp; Methods: The study involved a total of 46 subjects with choledocholithiasis, who were categoryed in 2 categorys. Category I as a drainage category of stents and Category 2 as a drainage category of T-tubes. The subjects in both classes underwent LCBDE surgery. Of the 46 subjects operated, 23 were in category I (stent drainage category) and 23 were in category 2 (T-tube drainage category). &#x0D; Results: 23 subjects were categoryed in the stent drainage and T-tube drainage categories, respectively. In both classes, no perioperative or postoperative mortality was reported. Subjects had hypertension in stent drainage category 4 (17.39 percent) and 5 (21.73 percent) suffered from diabetes as a comorbid disease, while 2 (8.69 percent) subjects had jaundice. Four (17.39 percent) subjects with diabetes and three (13.04 percent) subjects with jaundice were found in T-tube drainage category 3 (13.04 percent) with hypertension. In both classes, no statistically significant difference was found. In terms of organisational results and outcomes, statistically significant variations were found in both categorys (Table 3). Mean operating time was 103± 22.4 in category I while 127±32.7 (P value &lt; 0.005) in category II. In the Stent Drainage Category, blood loss during procedure was 22±3.7 ml, while in the T-tube drainage category it was 38±5.1 (P value &lt; 0.005).&#x0D; Conclusion. After laparoscopic choledochotomy, primary closure of the bile duct with spontaneously reversible biliary stent placement is a viable and practicable process. With spontaneously removable biliary stents, less surgery time, less bleeding and less intestinal complications have been observed.&#x0D; Keywords: stent drainage, T- tube drainage, choledochotomy

AN ACCOUNT OF 15 YEARS EXPERIENCE OF LAPAROSCOPIC COMMON BILE DUCT EXPLORATION IN CHOLEDOCHOLITHIASIS FOLLOWED BY PRIMARY REPAIR AND ITS COMPARISON WITH OPEN CHOLEDOCHOLITHOTOMY IN DISHARI HEALTH POINT PRIVATE LIMITED, MALDA

A retrospective study of 4628 patients who underwent laparoscopic cholecystectomies with choledocholithotomy with primary repair of common bile duct , with a mean follow-up of 23.2 months is carried outto evaluate the safety and feasibility of laparoscopic choledocholithotomy via choledochotomy for the treatment of choledocholithiasis in Dishari Health Point Private Limited, a multispeciality hospital in Malda from January 2004 to January 2019. We had to convert to open surgery in 27 patients and could complete the operation laparoscopically in rest 4621 patients. We also did open surgery in 30 patients apart from this. We analyse the results and it was found that Laparoscopic bile duct exploration via choledochotomy followed by primary duct closure is feasible and safe for the treatment of choledocholithiasis.

Reinterventions following laparoscopic cholecystectomy and bile duct exploration. A review of prospective data from 5740 patients

BackgroundComplications following laparoscopic cholecystectomy (LC) and common bile duct exploration (CBDE) for the management of gallstones or choledocholithiasis impact negatively on patients’ quality of life and may lead to reinterventions. This study aims to evaluate the causes and types of reintervention following index admission LC with or without CBDE.MethodsA prospectively maintained database of LC and CBDE performed by a single surgeon was analysed. Preoperative factors, difficulty grading and perioperative complications requiring reintervention and readmissions were examined.ResultsReinterventions were required in 112 of 5740 patients (2.0%), 89 (1.6%) being subsequent to complications. The reintervention cohort had a median age of 64 years, were more likely to be females (p < 0.0023) and to be emergency admissions (67.9%, p < 0.00001) with obstructive jaundice (35.7%, p < 0.00001). 46.4% of the reintervention cohort had a LC operative difficulty grade IV or V and 65.2% underwent a CBDE. Open conversion was predictive of the potential for reintervention (p < 0.00001). The most common single cause of reintervention was retained stones (0.5%) requiring ERCP followed by bile leakage (0.3%) requiring percutaneous drainage, ERCP and relaparoscopy. Relaparoscopy was necessary in 17 patients and open surgery in 13, 6 of whom not resulting from complications. There were 5 deaths.ConclusionThis large series had a low incidence of reinterventions resulting from complications in spite of a high workload of index admission surgery for biliary emergencies and bile duct stones. Surgical or endoscopic reinterventions following LC alone occurred in only 0.8%. The most common form of reintervention was ERCP for retained CBD stones. This important outcome parameter of laparoscopic biliary surgery can be optimised through early diagnosis and timely reintervention for complications.

Choledochus angulation by T-tube.

The presence of bile stasis is a frequent mechanism for presenting choledocholithiasis and recurrence of this one. The bile duct angulation, also known as "elbow sign," could be a risk factor for reducing the flow of bile and forming stones and it has been reported as a consequence secondary to the use of T-tube. The recurrence of choledocholithiasis without the use of T-tube in the bile duct is minimal, whereas in those with T-tube is four times higher in bile duct exploration surgeries. We present a case report of a patient who underwent T-tube laparoscopic bile duct exploration surgery, who had a bile duct angulation and residual choledocholithiasis as a complication. 34-yeard-old female, who presented acute cholecystitis and underwent cholecystectomy. In this operation it was detected choledocholithiasis, which is why it was carried out a T-tube bile duct exploration surgery for acute cholecystitis, without solving the choledocholithiasis condition. Afterwards, she had three endoscopic retrograde cholangiopancreatography procedures, requiring endoscopic hemoclip. Four months later, she was referred to a third-level hospital for definitive treatment with unsolved choledocholithiasis. The bile duct angulation by T-tube is unusual and it favors bile duct dilatation, stasis of bile pigments and new stones formation. We consider that the best surgical option is the biliary bypass.

Outcomes of laparoscopic bile duct exploration for choledocholithiasis with small common bile duct.

BACKGROUNDLaparoscopic cholecystectomy (LC) combined with laparoscopic common bile duct (CBD) exploration (LCBDE) is one of the main treatments for choledocholithiasis with CBD diameter of larger than 10 mm. However, for patients with small CBD (CBD diameter ≤ 8 mm), endoscopic sphincterotomy remains the preferred treatment at present, but it also has some drawbacks associated with a series of complications, such as pancreatitis, hemorrhage, cholangitis, and duodenal perforation. To date, few studies have been reported that support the feasibility and safety of LCBDE for choledocholithiasis with small CBD.AIMTo investigate the feasibility and safety of LCBDE for choledocholithiasis with small CBD.METHODSA total of 257 patients without acute cholangitis who underwent LC + LCBDE for cholecystolithiasis from January 2013 to December 2018 in one institution were reviewed. The clinical data were retrospectively collected and analyzed. According to whether the diameter of CBD was larger than 8 mm, 257 patients were divided into large CBD group (n = 146) and small CBD group (n = 111). Propensity score matching (1:1) was performed to adjust for clinical differences. The demographics, intraoperative data, short-term outcomes, and long-term follow-up outcomes for the patients were recorded and compared.RESULTSIn total, 257 patients who underwent successful LC + LCBDE were enrolled in the study, 146 had large CBD and 111 had small CBD. The median follow-up period was 39 (14-86) mo. For small CBD patients, the median CBD diameter was 0.6 cm (0.2-2.0 cm), the mean operating time was 107.2 ± 28.3 min, and the postoperative bile leak rate, rate of residual CBD stones (CBDS), CBDS recurrence rate, and CBD stenosis rate were 5.41% (6/111), 3.60% (4/111), 1.80% (2/111), and 0% (0/111), respectively; the mean postoperative hospital stay was 7.4 ± 3.6 d. For large CBD patients, the median common bile duct diameter was 1.0 cm (0.3-3.0 cm), the mean operating time was 115.7 ± 32.0 min, and the postoperative bile leak rate, rate of residual CBDS, CBDS recurrence rate, and CBD stenosis rate were 5.41% (9/146), 1.37% (2/146), 6.85% (10/146), and 0% (0/146), respectively; the mean postoperative hospital stay was 7.7 ± 2.7 d. After propensity score matching, 184 patients remained, and all preoperative covariates except diameter of CBD stones were balanced. Postoperative bile leak occurred in 11 patients overall (5.98%), and no difference was found between the small CBD group (4.35%, 4/92) and the large CBD group (7.61%, 7/92). The incidence of CBDS recurrence did not differ significantly between the small CBD group (2.17%, 2/92) and the large CBD group (6.52%, 6/92).CONCLUSIONLC + LCBDE is safe and feasible for choledocholithiasis patients with small CBD and did not increase the postoperative bile leak rate compared with chole-docholithiasis patients with large CBD.

Laparoscopic Management of Common Bile Duct Stones: Stratifying Risks, a District Hospital Experience.

Background: Management of bile duct stones is variable. Selection of the appropriate treatment modality based on identifiable risk factors can increase the chances of a successful outcome. The aim of this study is to identify factors affecting outcomes of a laparoscopic bile duct exploration. Methods: Retrospective data analysis of consecutive laparoscopic bile duct explorations over a period of 13 years at a district general hospital. Results: The total number of patients in the study was 85. Elective explorations were 56 while 29 were emergency procedures. The mean operative time was 154 minutes. The conversion rate was 14% with failure to extract stones being the most common reason. Forty-two percent of conversions were in nonelective procedures and 17% in previous endoscopic retrograde cholangiopancreatography (ERCP) failures. Eleven percent patients had a transcystic clearance of bile duct and the largest stone removed transcystic was 5 mm. The largest stone removed by a laparoscopic choledochotomy was 15 mm and stones >20 mm were removed on conversion. Seven patients (8%) had a postoperative bile leak, 4 of these required a postoperative ERCP stent and radiological drainage while 3 required a reoperation. Three patients had retained stones treated by postoperative ERCP. Conclusion: Emergency procedures, increasing number and size of stones, previous failed ERCP are factors that contribute to the outcomes of a laparoscopic bile duct exploration. The chances of a successful exploration can be improved by appropriate patient and procedure selection and preparation based on identification of these factors.

Open conversion in laparoscopic cholecystectomy and bile duct exploration: subspecialisation safely reduces the conversion rates

BackgroundOpen conversion rates during laparoscopic cholecystectomy vary depending on many factors. Surgeon experience and operative difficulty influence the decision to convert on the grounds of patient safety but occasionally due to technical factors. We aim to evaluate the difficulties leading to conversion, the strategies used to minimise this event and how subspecialisation influenced conversion rates over time.MethodsProspectively collected data from 5738 laparoscopic cholecystectomies performed by a single surgeon over 28 years was analysed. Routine intraoperative cholangiography and common bile duct exploration when indicated are utilised. Patients undergoing conversion, fundus first dissection or subtotal cholecystectomy were identified and the causes and outcomes compared to those in the literature.Results28 patients underwent conversion to open cholecystectomy (0.49%). Morbidity was relatively high (33%). 16 of the 28 patients (57%) had undergone bile duct exploration. The most common causes of conversion in our series were dense adhesions (9/28, 32%) and impacted bile duct stones (7/28, 25%). 173 patients underwent fundus first cholecystectomy (FFC) (3%) and 6 subtotal cholecystectomy (0.1%). Morbidity was 17.3% for the FFC and no complications were encountered in the subtotal cholecystectomy patients. These salvage techniques have reduced our conversion rate from a potential 3.5% to 0.49%.ConclusionAlthough open conversion should not be seen as a failure, it carries a high morbidity and should only be performed when other strategies have failed. Subspecialisation and a high emergency case volume together with FFC and subtotal cholecystectomy as salvage strategies can reduce conversion and its morbidity in difficult cholecystectomies.

Treatment of choledocolithiasis by laparoscopic exploration of the bile tract after failed endoscopic retrograde cholangiopancreatography

IntroductionThere are three treatment options for choledocholithiasis: endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy; laparoscopic exploration of the main bile duct with concomitant cholecystectomy; and open cholecystectomy with exploration of the main bile duct. Material and methodsA retrospective, descriptive, observational study was taken of patients with a diagnosis of cholecysto-choledocholithiasis that failed ERCP and who underwent laparoscopic cholecystectomy with exploration of the bile duct. ResultsFrom January 2009 to December 2018, 2322 ERCP procedures were performed at Hospital Regional Ignacio Zaragoza, with a failed procedure rate of 3.2% which is equivalent to 75 patients; endoscopic sphincterotomy was performed on all 75 patients and 60 (80%) of these patients had cholelithiasis with choledocholithiasis. Access to the bile duct through choledochotomy was required in all 75 patients, achieving successful stone extraction and bile duct clearance in 95%. Fifteen (20%) of these patients that had had laparoscopic cholecystectomy presented choledocholithiasis de novo more than two years after cholecystectomy. Nine patients underwent laparoscopic cholecystectomy and 6 patients underwent open cholecystectomy. Patients averaged 6 hospital days post-procedure. Surgical times ranged from 150 min to 210 min. ConclusionLaparoscopic reoperation of the biliary tract is a reasonable alternative for patients with a history of previous biliary surgery who have failed the ERCP approach.

Primary Closure versus T Tube Drainage in Laparoscopic Common Bile Duct Exploration: Has the Paradigm Already Changed?

Purpose: The question of how to close de common bile duct (CBD) following of laparoscopic bile duct exploration (LCBDE) remains a topic of debate. Traditionally, the CBD is closed with T-tube drainage after choledochotomy and removal of CBD stones. With advances in laparoscopic instrumentation and acquisition of advanced laparoscopic skills primary duct closure without a T-tube has been proposed as an alternative. In recent studies primary closure has been showing less complications, shorter hospitalization stay and reduced operative times discouraging the routine use of T-tube after LCBDE. The aim of this study is to compare the safety and effectiveness of primary closure with T-tube drainage in laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis. Method: Observational, retrospective study of patients undergoing LCBDE between January 2012 and May 2020. Descriptive and statistical analysis was performed with SPSS 25. Results: 71 patients underwent LCBDE with a transcholedochal approach (62% female, median age 67 years). Choledocoscopy was executed in 46.5% of the patients. Primary closure rate was 29.6%. The T-Tube group had a higher complications rate (24.5% vs 23.8%) and an inferior CBD stone clearance rate (87,8% vs 90.5%). The reintervention (7% vs 4.8%) and the hospital stay were superior in the T-tube group (7.6 vs 5.8 days). Conclusion: Primary closure was adopted as a preferred method in recent years in our hospital. Even with these previous results, we can assume that primary closure is feasible and associated with fewer complications, less need for reintervention and shorter hospital stay than T-tube drainage. Based on these results, primary duct closure may be considered as the optimal procedure for CBD closure after LCBDE.

A Snapshot of the Practice of Laparoscopic Common Bile Duct Exploration in the United Kingdom - (CholeS Data Set)

Introduction: The aim was to describe the utilisation/practice of laparoscopic bile duct exploration(LCBDE) option for the management of common bile duct stones across the UK. The data were obtained from a population-based cohort study of outcomes following cholecystectomy for benign gallbladder diseases (CholeS study). Methods: We used the CholeS Study DataSet to analyse the use of LCBDE in the UK. Descriptive analysis and graphs were used to illustrate the current practice of LCBDE in the UK. Results: Seventy-seven (46%) out of 167 Hospitals that took part in the CholeS study performed LCBDE. Their LCBDE workload was 5.4% out of the total Laparoscopic Cholecystectomies(LC) performed. Almost 90% of LCBDE was performed by hospitals who performed less than five LCBDE in two months. Only 5.2% of hospitals performed more than 10 LCBDEs; this accounts for 19.8% of their LC workload compared to between 2 and 8% for the rest. Out of 8820 LC, a total of 256(2.9%) and 932(10.6%) patients underwent LCBDE and pre-operative endoscopic retrograde cholangio-pancreatography and sphincterotomy(ERCP+ES) respectively for CBDS. Eighty-four per cent of LCBDEs were performed by Upper gastrointestinal surgeons and 16% by other specialities including 10% colorectal surgeons. Interestingly, only just under 5% of the LCBDEs were performed by trainees. Conclusions: In the UK, a significant proportion of patients with CBDS are still treated in two stages: a pre-operative ERCP followed by LC. LCBDE remains an underutilised resource in the UK. Further studies are required to examine the possible reasons for the low utilisation of LCBDE.

Laparoscopic Bile Duct Exploration as a One-stage Treatment for Choledocholithiasis. Cost-effectiveness Study Compared to ERCP Followed by Laparoscopic Cholecystectomy

Laparoscopic Bile Duct Exploration as a One-stage Treatment for Choledocholithiasis. Cost-effectiveness Study Compared to ERCP Followed by Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy with bile duct exploration during Covid 19 pandemic

The incidence of gallstones varies from 6%-10% in the adult population. Three percent to 14.7% of patients with gallstones have concurrent common bile duct stones as well. The current treatment of common bile duct stones remains controversial with the debate between endoscopic cholangiopancreatography and common bile duct exploration. This is a 27-year-old female with 5 days of evolution of abdominal pain, the patient with cholelithiasis has already been known, the patient with jaundiced conjunctiva, total bilirubin 4.2, and direct bilirubin 3.8, a test for covid 19 with polymerase chain reaction is performed, resulting in this positive. The patient goes under surgery with the corresponding protective equipment for covid 19, where a cholecystectomy with laparoscopic bile duct exploration is performed without incidents, the patient is discharged 24 hours after surgery, with a total bilirubin of 1, direct bilirubin of 0.5, without clinical data of covid 19, discharge with alarm data for covid 19.

Optimising the Outcomes of Index Admission Laparoscopic Cholecystectomy and Bile Duct Exploration for Benign Biliary Emergencies: A Service Model

Optimising the Outcomes of Index Admission Laparoscopic Cholecystectomy and Bile Duct Exploration for Benign Biliary Emergencies: A Service Model

Lessons learnt from the first 200 unselected consecutive cases of laparoscopic exploration of common bile duct stones at a district general hospital.

The management of choledocholithiasis evolves with diagnostic imaging and therapeutic technology, facilitating a laparoscopic approach. We review our first 200 cases of laparoscopic exploration of the common bile duct, highlighting challenges and lessons learnt. We retrospectively studied the first 200 cases of laparoscopic cholecystectomy with common bile duct exploration between 2006 and 2019. The database contains demographics, clinicopathological characteristics, diagnostic modalities, operative techniques, duration and outcomes. We compared two approaches: transcystic vs. transcholedochal in our 200 cases. Choledocholithiasis was suspected preoperatively in 163 patients. 21 cases found no stones. Of the remainder, 111/179 cases were completed via the transcystic route and the remaining were completed transcholedochally (68/179); 25% of the transcholedochal cases were converted from a transcystic approach. CBD diameter for transcystic route was 8.2 vs. 11.0mm for transcholedochal. Total clearance rate was 84%. Retained or recurrent stones were noted in 7 patients. Length of stay was 5.8days, 3.5days in the transcystic route vs. 9.4days after transcholedochal clearance. Eight patients required re-operation for bleeding or bile leak. No mortalities were recorded in this cohort, but 2 cases (1%) developed a subsequent CBD stricture. Concomitant laparoscopic common bile duct clearance with cholecystectomy is feasible, safe and effective in a district general hospital, despite constraints of time and resources. The transcystic route has a lower complication rate and shorter hospital stay, and hence our preference of this route for all cases. Advancements in stone management technology will allow wider adoption of this technique, benefitting more patients.

Laparoscopic Exploration of the Common Bile Duct: A Systematic Review of the Published Evidence Over the Last 10 Years.

Endoscopic and open surgical interventions are widely implemented as the standard practice in common bile duct exploration. However, the laparoscopic approach has been also reported to have comparative/superior outcomes in this concept. This has created an ongoing debate about the ideal approach to adopt in practice. A systematic review of the published evidence over the last decade that has looked into the outcomes of laparoscopic exploration of the common bile duct through transductal and transcystic approaches. Our systematic review included 36 relevant papers. The majority were based on nonrandomized protocols conducted in single centers with high expertise. The data analysis showed that laparoscopic common bile duct exploration through both approaches was successful in more than 84% of the patients, with an average length of hospital stay of 5.6 days. Conversion to open surgery was reported in 5%-8% of the patients, and the bile leak rates from the more recent studies was 0%-12%, with mortality figures of 0%-1.3%. The outcomes were statistically in favor of the transcystic route when compared to the transductal route from the viewpoints of bile leak rates, mean operative time, duration of hospital stay and morbidity. In experienced hands, both laparoscopic approaches in common bile duct exploration are safe in patients who are clinically fit to have this intervention. It is associated with a statistically significant lower overall morbidity and shorter duration of hospital stay when compared to open surgery. Relevant up-to-date high-quality randomized trials are unavailable.

Optimising the outcomes of index admission laparoscopic cholecystectomy and bile duct exploration for biliary emergencies: a service model

AimsThe rate of acute laparoscopic cholecystectomy remains low due to operational constraints. The purpose of this study is to evaluate a service model of index admission cholecystectomy with referral protocols, refined logistics and targeted job planning.MethodsA prospectively maintained dataset was evaluated to determine the processes of care and outcomes of patients undergoing emergency biliary surgery. The lead author has maintained a 28 years prospective database capturing standard demographic data, intraoperative details including the difficulty of cholecystectomy as well as postoperative outcome parameters and follow up data.ResultsOver five thousand (5555) consecutive laparoscopic cholecystectomies were performed. Only patients undergoing emergency procedures (2399,43.2% of entire group) were analysed for this study. The median age was 52 years with 70% being female. The majority were admitted with biliary pain (34%), obstructive jaundice (26%) and acute cholecystitis (16%). 63% were referred by other surgeons. 80% underwent surgery within 5 days (40% within 24 h). Cholecystectomies were performed on scheduled lists (44%) or dedicated emergency lists (29%). Two thirds had suspected bile duct stones and 38.1% underwent bile duct exploration. The median operating time was 75 min, median hospital stay 7 days, conversion rate 0.8%, morbidity 8.9% and mortality rate 0.2%.ConclusionIndex admission cholecystectomy for biliary emergencies can have low rates of morbidity and mortality. Timely referral and flexible theatre lists facilitate the service, optimising clinical results, number of biliary episodes, hospital stay and presentation to resolution intervals. Cost benefits and reduced interval readmissions need to be weighed against the length of hospital stay per episode.

Decision analysis of minimally invasive management options for cholecysto-choledocholithiasis.

The management of cholecysto-choledocholithiasis is controversial with the risks and benefits of one versus two-stage approaches debated. This study aims to perform decision analysis of minimally invasive laparo-endoscopic approaches. An advanced decision tree was constructed to compare pre, intra and post-operative ERCP and laparoscopic common bile duct exploration in terms of primary ductal clearance and significant complications for patients intended to undergo laparoscopic cholecystectomy. Transition probabilities were calculated from randomised controlled trials following a comprehensive literature search. Model uncertainties were extensively tested through deterministic and probabilistic Monte Carlo sensitivity analysis. Utility outcomes were 1 and 0.5 for successful primary clearance without and with complications, respectively, and 0 for failure of primary clearance of the duct. Twenty-one studies (n = 2697) were included in the analysis. At base case analysis, a laparo-endoscopic rendezvous approach had the highest utility output (0.90; no complication probability: 0.87/complication probability 0.06). Laparoscopic common bile duct exploration was ranked second with a utility output 0.87 (no complication probability: 0.82/complication probability 0.10). Pre-operative ERCP utility score was 0.84 (no complication probability: 0.78/ complication probability 0.11) and post-operative ERCP utility score was 0.78 (no complication probability: 0.71/complication probability 0.13). Monte Carlo analysis showed that laparo-endoscopic rendezvous and laparoscopic common bile duct exploration had an equal mean utility output of 0.57 (standard deviation 0.36; variance 0.13; 95% confidence interval 0.00-0.99 versus standard deviation 0.34; variance 0.12; 95% confidence interval 0.01-0.98). Laparo-endoscopic rendezvous had a superior treatment selection frequency of 39.93% followed by laparoscopic bile duct exploration (36.11%), pre-operative ERCP (20.67%) and post-operative ERCP (2.99%). One-stage approach to the management of cholecysto-choledocholithiasis is superior to two-stage, in terms of primary clearance of the duct and risk of operative morbidity. Laparo-endoscopic rendezvous approach could offer marginal additional benefit but more high-quality randomised controlled trials are needed.

Innovative hybrid technique of bile duct exploration in the treatment of Choledocolithiasis

Common bile stone disease (CBDS) is frequent and has potentially severe complications, such as acute biliary pancreatitis and cholangitis. Unnecessary and unplanned procedures must be avoided, so before choosing the best treatment of common bile duct lithiasis it is essential to have a proper diagnose. CBDS is currently treated by therapeutic endoscopic retrograde cholangiopancreatography (ERCP) or laparoscopic bile duct exploration (LCBDE). The aim of this article is to present a innovative hybrid technique of common bile duct exploration, on account of one option in those cases where the laparoscopic approach is not resolutive, avoiding the need of conversion to open approach technique. The hybrid technique has the same benefits of open and laparoscopic techniques, but without increasing costs with material and with good resolutivity in complex cases of common bile duct stones. Keywords: Choledocholithiasis; laparoscopic common bile duct exploration; LCBDE; open common bile duct exploration