Laparoscopic Common Bile Duct Exploration Research Articles

2-Port incision laparoscopic common bile duct exploration: experience in the Philippines

2-Port incision laparoscopic common bile duct exploration: experience in the Philippines

A single center experience of single-stage laparoscopic cholecystectomy and common bile duct exploration

A single center experience of single-stage laparoscopic cholecystectomy and common bile duct exploration

Single-stage laparoscopic cholecystectomy (LC) and common bile duct exploration (LCBDE) versus two-stage ERCP followed by LC for patients with concomitant Gallstones and CBD stones

Single-stage laparoscopic cholecystectomy (LC) and common bile duct exploration (LCBDE) versus two-stage ERCP followed by LC for patients with concomitant Gallstones and CBD stones

Outcomes of laparoscopic choledochotomy using cholangioscopy via percutaneous-choledochal tube for the treatment of hepatolithiasis and choledocholithiasis: A preliminary Vietnamese study.

Hepatolithiasis and choledocholithiasis are frequent pathologies and unfortunately, with the current treatment strategies, the recurrence incidence is still high. This study aimed to assess the outcomes of laparoscopic choledochotomy using cholangioscopy via the percutaneous-choledochal tube for the treatment of hepatolithiasis and choledocholithiasis in Vietnamese patients. A cross-sectional study of patients with hepatolithiasis and/or choledocholithiasis who underwent laparoscopic choledochotomy using intraoperative cholangioscopy via percutaneous-choledochal tube at the Department of Hepatopancreatobiliary Surgery, 108 Military Central Hospital, from June 2017 to March 2020. A total of 84 patients were analyzed. Most patients were females (56.0%) with a median age of 55.56 years. Among them, 41.8% of patients had previous abdominal operations, with 33.4% having choledochotomy. All patients underwent successful laparoscopic common bile duct exploration followed by T-tube drainage without needing to convert to open surgery. Most patients (64.3%) had both intrahepatic and extrahepatic stones. The rate of stones ≥ 10 mm in diameter was 64.3%. Biliary strictures were observed in 19.1% of patients during cholangioscopy. Complete removal of stones was achieved in 54.8% of patients. Intraoperative complications were encountered in two patients, but there was no need to change the strategy. The mean operating time was 121.85 ± 30.47 minutes. The early postoperative complication rate was 9.6%, and all patients were managed conservatively. The residual stones were removed through the T-tube tract by subsequent choledochoscopy in 34/38 patients, so the total success rate was 95.2%. Laparoscopic choledochotomy combined with cholangioscopy through the percutaneous-choledochal tube is a safe and effective strategy for hepatolithiasis and/or choledocholithiasis, even in patients with a previous choledochotomy.

Comparison of Intraoperative ERCP vs Laparoscopic Common Bile Duct Exploration for CBD Stones in an Under-resourced Setting

Comparison of Intraoperative ERCP vs Laparoscopic Common Bile Duct Exploration for CBD Stones in an Under-resourced Setting

Feasibility and safety of choledochotomy primary closure in laparoscopic common bile duct exploration without biliary drainage: a retrospective study

Common bile duct (CBD) exploration and T-tube drainage are the main surgical methods for the removal of bile duct stones (BDSs), which can now be completed by laparoscopy. However, the feasibility and safety of primary closure of the CBD (PCCBD) in laparoscopic CBD exploration (LCBDE) without biliary drainage are still uncertain. From January 1, 2021, to June 30, 2022, patients who were diagnosed with BDSs and underwent LCBDE and primary closure of the CBD without biliary drainage in our hospital were included. The clinical and prognostic data of the patients were retrospectively analyzed to determine the feasibility and safety of PCCBD in LCBDE without biliary drainage. Forty-nine patients successfully underwent PCCBD in LCBDE without biliary drainage. The operation time was 158.8 ± 50.3 (90–315,150) minutes, the bile duct suture time was 17.6 ± 4.46 (10–26, 18) minutes, the intraoperative blood loss volume was 70.4 ± 52.6 (5–200, 80) ml, the hospitalization cost was 28,141.2 ± 7011.3 (15,005.45–52,959.34, 26,815.14) CNY Yuan, the hospitalization time was 13.22 ± 5.16 (8–32, 12) days, and the postoperative hospitalization time was 7.31 ± 1.94 (3–15, 7) days. There were 3 cases of postoperative bile leakage (3/49, 6.12%), all of them healed by nonsurgical treatment. During the follow-up of 17.2 ± 11.01 (10–26, 17) months, no residual BDSs, biliary stricture or other complications classified as Clavien-Dindo grade I or higher occurred. For some selected patients who meet certain criteria, PCCBD in LCBDE without biliary drainage is feasible and safe and is more conducive to the rapid postoperative recovery of patients.

Evaluation of the ACS NSQIP surgical risk calculator in patients undergoing common bile duct exploration.

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical risk calculator is a risk stratification tool to help predict risks of postoperative complications, which is important for informed decision-making. The purpose of this study was to evaluate the accuracy of the calculator in predicting postoperative complications in patients undergoing common bile duct (CBD) exploration. A retrospective chart review was completed for 305 patients that underwent open and laparoscopic CBD exploration at a single institution from 2010 to 2018. Patient demographics and preoperative risk factors were entered into the calculator, and the predicted complication risks were compared with observed complication rates. Brier score, C-statistic, and Hosmer-Lemeshow regression analysis were used to assess discrimination and calibration. The observed rate exceeded the predicted rate for any complication (35.1% vs. 21%), return to operating room (5.9% vs. 3.6%), death (3.3% vs. 1%), and sepsis (3% vs. 2.4%). The model performed best in predicting serious complication (Brier 0.087, C-statistic 0.818, Hosmer-Lemeshow 0.695), surgical site infection (Brier 0.068, C-statistic 0.670, Hosmer-Lemeshow 0.292), discharge to rehabilitation facility (Brier 0.041, C-statistic 0.907, Hosmer-Lemeshow 0.638), and death (Brier 0.028, C-statistic 0.898, Hosmer-Lemeshow 0.004). In multivariable analysis, there was no statistically significant predicted complication type that affected the type of surgery. The calculator was accurate in predicting serious complication, surgical site infection, discharge to rehabilitation facility, and death. However, the model displayed poor predictive ability in all other complications that were analyzed.

OGBN P03 Surgeons’ perceptions of elective laparoscopic cholecystectomy in the post-COVID era

Abstract Background The COVID-19 pandemic has significantly impacted healthcare systems worldwide, leading to modifications in surgical practices. Laparoscopic cholecystectomy (LC), a common elective procedure, has faced challenges in the post-COVID era, with increased waiting times and episodes of acute gallstone disease in patients awaiting their procedure. This poses the question as to whether modifications to routine practice should be made. This study aims to explore surgeons' perceptions on performing laparoscopic cholecystectomy in the current post-pandemic landscape. Methods An anonymous survey was conducted among general surgeons with expertise in LC across multiple healthcare institutions nationally. The survey included questions relating to surgeons’ speciality, and their experience with elective LCs, intraoperative cholangiograms (IOC) and laparoscopic common bile duct exploration (LCBDE) in post-COVID era. Further opinions were sought on complicated intraoperative findings, rate of aborting procedure, rate of conversion to open and number of elective LCs completed by trainees. The data obtained was analysed using descriptive statistics and Fisher’s exact test for statistical significance calculations. Results 40 surgeons with varying levels of experience with LC completed the survey: 8 (20%) <50, 16 (40%) 100-500 LCs,10 (25%) 500->1000. Overall, 21 (53%) perceived LC to be more challenging. Analysis between the different groups found no significant difference (p = 0.68) between those who performed <50 LCs (6/8) and 500- >1000 LCs (6/10). 8 (20%) respondents found no increase in complicated intraoperative findings. Of those not working in specialist centres, 11/36 perceived an increase in referral to a hepatobiliary unit. 14 (35%) perceived an increase in unplanned admission. 21 (53%) perceived a reduction in completion of LC by trainees. Conclusions This study demonstrates that a significant proportion of respondents believe that LC has become more technically challenging. In patients with increased time till surgery or episodes of acute gallstone disease, MRCP should be considered at pre-assessment. Furthermore, during challenging LCs, options to ‘bail-out’ or convert to open should be considered. This study also raises awareness on the reduction in training opportunities and the need to ensure trainees progress appropriately. Limitations include small sample size and subjective nature of responses. Further research on patient outcomes is required to provide strong recommendations to optimise surgical practice of LC in the post-pandemic era.

OGBN O09V Multi-modal Approach with Fluorescence Imaging, Intraoperative Ultrasound and Laser Lithotripsy in the Laparoscopic Management of Complex Large Bile Duct Stones

Abstract Background Choledocholithiasis is a common condition with various presentations. There are several approaches through which this can be managed. This presentation aims to explain novel techniques and various modalities in managing complex bile duct stones successfully with minimal invasive approach. Methods This video presentation depicts the procedure performed for large CBD stones with the use of indocyanine green (ICG) and intraoperative ultrasound (IOUS). The patient is a 61 year old gentleman presented with abdominal discomfort and deranged liver functions. Cross sectional imaging showed 2 large CBD calculi and attempt at endoscopic retrograde cholangio-pancreatigoraphy (ERCP) failed due to large impacted stones. Decision was made to proceed to single stage laparoscopic cholecystectomy and common bile duct exploration with use of ICG, IOUS and laser lithotripsy to achieve successful clearance of CBD. Results At laparoscopy, the CBD and common hepatic artery were identified with ICG and IOUS. A vertical choledochotomy was performed and choledochoscopy undertaken. Attempts to retrieve the stone with extraction basket were not successful. Laser lithotripsy was used to break the stones into smaller fragments which were subsequently retrieved using atraumatic graspers and extraction wire. Post operative period was uneventful and the patient was discharged home on day 2. Face to face follow-up at 6 weeks confirmed good recovery. Conclusions Laparoscopic management of complex CBD stones is challenging. Despite advances in endoscopy intervention, the role of surgery is irrefutable. Advanced laparoscopic skills and experience in bile duct exploration with advanced minimally invasive instruments and equipment are critical to achieve optimal patient outcomes, and mitigated the chances of conversion to open surgery which its associated morbidity. This presentation demonstrates a safe technique while working in the hostile area of the inflamed hepatocystic triangle and an alternative method in the retrieval of large common bile duct stones following failed ERCP.

EGS P14 Improving Management of Obstructive Jaundice: A Single-Centre Experience

Abstract Background Timely management is essential in preventing recurrence of gallstone disease and The National Institute for Clinical Excellence (NICE) recommends that laparoscopic cholecystectomy (LC) should be performed within seven days of admission. However, there remains wide variation between NHS Trusts in managing gallstone disease. As part of an ongoing surgical quality improvement project, a restructured Upper Gastrointestinal Surgery (UGI) firm was created (with three dedicated UGI consultant surgeons, one specialist registrar, one foundation doctor), in close collaboration with interventional gastroenterologists and radiologists. The impact of this new service on gallstone disease management has been closely monitored. Methods A prospective database was maintained including patients presenting emergently with obstructive jaundice and/or common bile duct stones at our district general hospital (DGH) in the 6-month timeframe before (September 2021 to February 2022) and after (September 2022 to February 2023) implementation of the new UGI service. Outcomes included time from presentation to magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP) and LC. Results 26 and 38 patients with obstructive jaundice were admitted in the 6-month periods before and after UGI firm implementation, respectively. There were significant reductions in time from admission to receiving ERCP (6.6 days versus 40.2 days, p<.001), and outpatient LC (61.8 days versus 194 days, p=.02). There was also marked improvement in obtaining MRCP (2.5 days versus 5.2 days). After UGI firm implementation, 35% of eligible patients were offered an inpatient LC which were all performed within seven days (mean 6.3 days), versus none previously. Conclusions A dedicated UGI service significantly improved the treatment process for patients presenting with obstructive jaundice at our DGH. As part of ongoing quality improvement work, solutions such as introducing a ‘golden patient’ to the NCEPOD list, a ‘hot slot’ on the elective gallbladder list or a dedicated weekly ‘hot’ gallbladder list are currently being investigated. Equipment for laparoscopic transcystic common bile duct exploration is also being considered to alleviate the need for ERCP prior to surgery.

Laparoscopic common bile duct exploration: what factors determine success?

Laparoscopic common bile duct exploration (LCBDE) has been shown to be effective in managing choledocholithiasis whilst avoiding ERCP-related complications. However, patient and technical factors effects outcome. This study aimed to explore the matters effecting the failure of LCBDE. All patients who underwent a laparoscopic cholecystectomy (LC) between 2007 and 2021 were identified using a prospective database. Data were collected for patients who underwent LCBDE including demographics, pre-operative investigations, intra-operative findings, technique of bile duct clearance and clearance rates, and post-operative outcomes. Predictors of failed LCBDE were identified. Laparoscopic cholecystectomy was performed in 3648 patients. Of these, 374 underwent LCBDE for suspected choledocholithiasis. Choledochoscopy was most frequently used (58.8%) with a success rate of 84.1%. Small cystic duct diameter (4.7 vs. 3.4 mm, P = 0.002), stone size >6 mm (P = 0.02), stone: cystic duct ratio >1 (P = 0.04), and >3 stones was associated with failed LCBDE by univariate analysis. Small cystic duct diameter (OR: 0.45, 95% CI: 0.26-0.77, P = 0.004) and stone size >6 mm (OR: 0.23, 95% CI: 0.06-0.92), P = 0.04) correlated with failure by multivariate analysis. Failed LCBDE was associated with increased length of stay (6.6 days vs. 3.1 days, P = 0.001), however the rate of serious complications or mortality was unaffected. LCBDE is safe and effective in managing choledocholithiasis. Factors such as cystic duct diameter, size and number of CBD stones, and stone: cystic duct ratio are associated with increased likelihood of inadequate clearance. The presence of these factors can help clinicians in decision making during LCBDE to improve chance of success.

Transcystic Laparoscopic Common Bile Duct Exploration for Pediatric Patients with Choledocholithiasis: A Multi-Center Study

BackgroundPatients with choledocholithiasis are often treated with endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). Upfront LC, intraoperative cholangiogram (IOC), and possible transcystic laparoscopic common bile duct exploration (LCBDE) could potentially avoid the need for ERCP. We hypothesized that upfront LC+IOC +/- LCBDE will decrease length of stay (LOS) and the total number of interventions for children with suspected choledocholithiasis. MethodsA multicenter, retrospective cohort study was performed on pediatric patients (<18 years) between 2018 to 2022 with suspected choledocholithiasis. Demographic and clinical data were compared for upfront LC+IOC +/- LCBDE and possible postoperative ERCP (OR1st) versus preoperative ERCP prior to LC (OR2nd). Complications were defined as postoperative pancreatitis, recurrent choledocholithiasis, bleeding, or abscess. ResultsAcross four centers, 252 children with suspected choledocholithiasis were treated with OR1st (n=156) or OR2nd (n=96). There were no differences in age, gender, or body mass index. Of the LCBDE patients (72/156), 86% had definitive intraoperative management with the remaining 14% requiring postoperative ERCP. Complications were fewer and LOS was shorter with OR1st (3/156 vs. 15/96; 2.39 vs 3.84 days, p<0.05). ConclusionUpfront LC+IOC +/- LCBDE for children with choledocholithiasis is associated with fewer ERCPs, lower LOS, and decreased complications. Postoperative ERCP remains an essential adjunct for patients who fail LCBDE. Further educational efforts are needed to increase the skill level for IOC and LCBDE in pediatric patients with suspected choledocholithiasis. Level of EvidenceLevel III.

Ultrasound-Guided Percutaneous Transhepatic Cholangioscopic Lithotripsy for the Treatment of Common Bile Duct Stones and Analysis of Risk Factors for Recurrence.

As a minimally invasive treatment for common bile duct (CBD) stones, ultrasound-guided percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) is gaining attention and recognition from the medical community. A retrospective analysis was conducted on patients with CBD stones treated in our hospital from January 2016 to April 2022. Patients were divided into three groups: 77 treated with PTCSL, 93 with endoscopic retrograde cholangiopancreatography (ERCP), and 103 with laparoscopic common bile duct exploration (LCBDE). Their clinical data, perioperative indicators, and complications were analyzed comparatively. Then, risk factors for the post-PTCSL recurrence of CBD stones were analyzed by logistic regressions. Finally, the receiver operating characteristic curve was drawn. All perioperative indicators of the PTCSL group were better than the LCBDE group (P < 0.001). The incidences of cholangitis, hemobilia, and incisional infection after surgery were lower in the PTCSL group than in the LCBDE group (P < 0.05). Pancreatitis, reflux esophagitis, and papillary stenosis occurred less frequently in the PTCSL group than in the ERCP group (P < 0.05). Logistic regression analysis indicated that gallstones and family history were independent risk factors. The AUC for recurrent CBD stones predicted by multi-indicators was 0.895 (95% CI 0.792-0.999, P < 0.001) with a sensitivity of 96.7% and specificity of 68.8%. Ultrasound-guided PTCSL is a safe and effective treatment for CBD stones. Patients recovered quickly with fewer postoperative complications. It can be a first-line treatment for CBD stones. Gallstones and family history are independent risk factors for recurrent CBD stones, which provide a reference for clinicians in identifying the high-risk population needing close follow-up.

Comparative analysis of laparoscopic choledocholithiasis and ERCP treatment after cholecystectomy

ObjectiveTo compare the overall efficacy of laparoscopic common bile duct exploration(LCBDE) with endoscopic retrograde cholangiopancreatography (ERCP ) after cholecystectomy.MethodsFrom January 2017 to July 2021, Seventy patients with Choledocholithiasis after cholecystectomy who were admitted to our hospital were selected and divided into ERCP and LCBDE groups. comparison of baseline characteristics, clinical efficacy and postoperative complications between the ERCP and LCBDE.Results①The overall efficacy rate of LCBDE was 97.1%, while the overall efficacy rate in the ERCP group was 76.6%. The LCBDE group demonstrated a significantly higher overall effective rate compared to the ERCP group, with a statistically significant difference (p < 0.05). ②The preoperative and postoperative complications of the LCBDE group were visibly lower than the other group (P < 0.05). The postoperative time to oral intake, postoperative ventilation time, length of hospital stay, and hospital costs were higher in the ERCP group compared to the LCBDE group, with a statistically significant difference (P < 0.05).ConclusionIn the treatment of common bile duct stones after cholecystectomy, LCBDE is a superior choice compared to ERCP in terms of stone diameter, quantity, clearance rate, and hospital costs.

Endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy versus laparoscopic common bile duct exploration and cholecystectomy for cholecysto-choledocholithiasis − The same operator: a multicenter randomized controlled trial

Background Laparoscopic cholecystectomy (LC) plus either intraoperative endoscopic retrograde cholangiopancreatography (intraERCP) or laparoscopic common bile duct exploration (LCBDE) are one-stage, minimally invasive procedures to treat cholecysto-choledocholithiasis. This study aimed to compare the safety, efficacy, and surgical outcomes of the LC-intraERCP and LC-LCBDE for patients with cholecysto-choledocholithiasis. Both authors completely performed both procedures. Patients and methods This multicenter randomized controlled trial included 218 patients with cholecysto-choledocholithiasis randomized to LC-intraERCP (n = 109) and LC-LCBDE (n = 109) treatment groups between February 2019 and October 2022. The primary outcome was a technical success, while conversion to open surgery, operative time, morbidity, mortality, length of hospital stay, and cost were considered secondary outcomes. Results Both groups had no significant differences in success (94.5% for LC-intraERCP and 87.2% for LC-LCBDE) and morbidity rate. The conversion to open surgery, the mean operative time, the length of hospital stay, and the cost were significantly lower in the LC-intraERCP. There was no mortality in either group. Conclusion LC-intraERCP is safer and more effective than LC-LCBDE for treating cholecysto-choledocholithiasis. Moreover, it is associated with reduced hospital stay and cost.

Antegrade biliary stenting following surgical management of choledocholithiasis

Background: T-tube drainage of the common bile duct following bile duct exploration has been standard surgical practice for most of the past century. An important drawback of surgical duct exploration and clearance over ERCP is the need for prolonged external biliary drainage via T-tubes and consequently added morbidity. As such interest grew in reassessing the need for T-tube drainage after CBD Exploration. This was especially augmented by increased popularity of laparoscopic CBD exploration at the time of cholecystectomy which could provide a solution to both problems in a single sitting. Methods: This is a prospective observational study. We present a series of 31 cases of open and laparoscopic bile duct exploration where we closed the choledochotomy over an endo-biliary stent which was subsequently removed endoscopically, thus obviating external biliary drainage. Results: In this study 31 patients undergoing CBD exploration at our institution between January 2017 and August 2018 were included after informed consent. These patients underwent primary closure of the CBD over an endobiliary stent without any T-tube. The mean age of the patients was 42 years (36-57 yrs). 19 of the patients were female and 12 were male. The average operating time was 135 min (120-150 min) for open surgery and 160 min (140-170 min) for laparoscopic cases. The average number of days of hospitalization was 5 in laparoscopic cases (4-14 days) and 7 in open surgical cases (6-12 days). The median follow up of patients was up to 18moths years (8 mths-2 yrs). There were no cases of bilioma/intra-abdominal collections requiring drainage. On long term follow up we could not find any clinical/laboratory evidence of development of biliary strictures. Conclusions: Endobiliary stenting after open or laparoscopic bile duct exploration is a safe and attractive option for biliary drainage with many advantages over T-tube and can be achieved with minimal additional skill and operative time.

T‑tube versus internal drainage tube in laparoscopic common bile duct exploration.

The 203 patients who underwent laparoscopic common bile duct exploration for choledocholithiasis were retrospectively analyzed. The patients were divided into internal drainage tube group (n=87) and T-tube group (n=116). Total bilirubin, direct bilirubin, alanine aminotransferase (AST), aspartate aminotransferase (ALT), the diameter of common bile duct, number of stones, operation time, intraoperative bleeding, postoperative hospital stay and postoperative complications were compared between the two groups. Possible influencing factors were selected as independent variables, and the operation mode was selected as the dependent variable for multifactor unconditional logistic regression analysis. There were no significant differences in the sex, age, total bilirubin, direct bilirubin, AST, ALT, operation time, intraoperative blood loss, postoperative hospital stay and postoperative biliary leaks between the two groups (P>0.05). The diameter of the common bile duct was smaller and the incidence of multiple stones in the common bile duct was lower in the internal drainage tube group compared with that in the T-tube group (P<0.05). The results of multifactor unconditional logistic regression analysis demonstrated that the diameter of the common bile duct and the number of stones in the common bile duct were associated with the operation mode as influencing factors. In conclusion, Patients with multiple stones in the common bile duct or with a wide diameter of the common bile duct are more likely to have T-tube placed rather than an internal drainage tube.

Endoscopic retrograde cholangiopancreatography as a single-modality 'gold-standard' treatment for common bile duct stones in the elderly.

There are more octogenarians presenting with gallstone disease each year. Many are not suitable for surgical intervention. An alternative treatment option for common bile duct stones in the elderly is endoscopic retrograde cholangiopancreatography (ERCP) with or without stent insertion. We conducted a retrospective study using a prospectively collected database, analysing the outcomes of consecutive patients >80 years old who underwent an ERCP in a single centre for the treatment of common bile duct stones. In total, 156 patients, with a median age of 91 years, underwent an ERCP for choledocholithiasis over a 3-year period. ERCP was successful in 90% of patients but a proportion required repeat intervention. Forty-six (29%) patients had a concurrently inserted stent due to incomplete stone extraction. Six (4%) patients required a post-ERCP cholecystectomy due to ongoing symptoms. The overall ERCP complication rate was 7% (4% Clavien-Dindo 1 and 3% Clavien-Dindo 2), with no cases of post-ERCP pancreatitis or death. Patients were followed up over 5 years following index ERCP. There was a 60% 3-year survival and 30% 5-year survival rate following index ERCP. Importantly, of those who did not survive, only four patients (2.6%) had a death attributable to a biliary cause and none were fit for definitive surgery. ERCP can be considered as a possible definitive management option for treating common bile duct stones in the elderly, particularly in the comorbid population. Concurrent stenting is an effective temporizing strategy and mitigator of biliary-related readmission, but routine stent changes should be considered. Key messages What is already known on this topic Current guidelines advocate for laparoscopic cholecystectomy and common bile duct exploration in patients with choledocholithiasis. What this study adds Endoscopic retrograde cholangiopancreatography with or without stent insertion is a safe, alternative single-treatment modality for choledocholithiasis in the elderly comorbid population. How this study might affect research, practice, or policy Studies and guidelines evaluating treatment options for choledocholithiasis may be altered to accommodate patient-specific factors, including age and comorbid status, and the concurrent use of stenting as a either a temporizing or longer-term measure for complex stone disease.

Transcystic versus transcholedochal laparoscopic common bile duct exploration: Choosing the right approach – A Case Series

Laparoscopic common bile duct exploration (LCBDE) is a relevant therapeutic option in managing cholecysto-choledocholithiasis. The success of this procedure is highly dependent on selecting an appropriate method, either transcystic or transcoledocal. Intraoperative choledochoscopy proves its importance in evaluating the condition of the choledochal duct and sphincter of Oddi. In this case series, we report 2 cases of patients with complaints of right upper abdominal pain and jaundice. Both patients were diagnosed with multiple cholecysto-choledocholithiasis at Dr. Sardjito Hospital, Yogyakarta. The interventional measures applied to both patients were transcystic and transcoledocal exploration. In the first patient, the transcystic method was chosen because the cystic duct was widening up to 9 mm in diameter. While in the second patient, the transcoledocal method was taken because the diameter of the cystic duct was still within normal limits. The duration of surgery in transcystic surgery was shorter than in transcoledocal surgery, with a time ratio of 129 minutes versus 162 minutes. Postoperatively, both patients were discharged on the second day after the procedure, and both experienced recovery without any significant complications. Overall, LCBDE has been shown to be safe to perform. The one-stage surgical approach has been shown to reduce the risk of complications, cost, and duration of treatment required. The choice between the transcystic or transcoledocal method should be based on each patient’s clinical condition.

WTP3.4 Improvement of biliary service in hospital by altering the management of suspected or confirmed bile duct stones. Confirmed bile duct stones can be managed by single-stage procedure of laparoscopic cholecystectomy (LC) plus common bile duct exploration (CBDE). Intra-operative cholangiogram (IOC) can be used to avoid delays waiting for MRCP

Abstract Background Significant delays can follow the process of emergency admissions with biliary problems in hospitals. Routine pathway for gallstones and abnormal liver functions tests (LFTs) is ultrasound (US) followed by MRCP. Pathway for confirmed common bile duct (CBD) stones has been routinely an ERCP followed by LC either as inpatient or outpatient. Significant delays take place awaiting MRCP considering that there is no out-of-hours or weekend service, while ERCP lists only occur twice weekly for both emergency and elective which can lead to unnecessary delays. Methods An audit was performed for 2 months period from 1st October 2022 to 30th November 2022 to assess how patients were managed in the department. Results A total of 16 emergency LCs were done in this period. 3 of them had ERCP prior to operation while 5 had MRCP prior to exclude CBD stones. Average length of stay (LOS) for these 8 patients was 7 days. It was estimated that LOS for these patient would have been reduced to 4 days if IOC +/- CBDE were done. A total of 37 ERCPs were done in the same period. 22 of them were done as emergency of which 12 were for CBD stones, 7 for cancers and 3 for bile leak. 7 of the 12 emergency ERCPs for CBD stones would have benefited from one stage procedure of LC + CBDE reducing their LOS and leaving space for other cases in ERCP lists. Conclusion A dedicated weekly IOC/CBDE list was proposed to overcome this problem.