Laparoscopic Transcystic Common Bile Duct Research Articles

Intraoperative transcystic laparoscopic common bile duct stone clearance with SpyGlass™ discover during emergency and elective cholecystectomy: a single-center case series

Background and study aimThe development of a new cholangioscope, the SpyGlass™ Discover (Boston Scientific), has allowed the laparoscopic transcystic common bile duct exploration and stone clearance. The possibility of simultaneous treatment of choledocholithiasis during early laparoscopic cholecystectomy offers the opportunity to enormously reduce the time between acute cholecystitis diagnosis and the execution of cholecystectomy with better outcomes for patients. Furthermore, an altered anatomy of the gastrointestinal tract is not an obstacle to this technique. The aim of the study was to determine whether this new procedure is feasible, safe, and effective.Patients and methodsThe investigation employs a retrospective case series study including all consecutive patients with a diagnosis of common bile duct stones undergoing cholecystectomy and intraoperative laparoscopic common bile duct clearance using SpyGlass™ Discover at IRCCS Policlinico San Matteo in Pavia (Italy). Eighteen patients were included from May 2022 to May 2023.ResultsA complete clearance of the common bile duct was obtained in 88.9% of patients. The mean postoperative length of stay was 3 days. No major complications occurred. After a median follow-up of 8 months, no recurrence of biliary events or readmissions occurred.ConclusionThis procedure has proven to be feasible, safe, and effective.

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.

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.

Laparoscopic transcystic common bile duct exploration versus transgastric endoscopic retrograde cholangiography during cholecystectomy after Roux-en-Y gastric bypass.

Treatment of common bile duct (CBD) stones after Roux-en-Y gastric bypass (RYGB) poses a particular challenge given the altered anatomy and inability to perform a standard endoscopic retrograde cholangiogram (ERC). The optimal treatment strategy for intraoperatively encountered CBD stones in post-RYGB patients has not been established. To compare outcomes following laparoscopic transcystic common bile duct exploration (LTCBDE) and laparoscopy-assisted transgastric ERC for CBDs during cholecystectomy in RYGB-operated patients. Swedish nationwide multi-registry study. The Swedish Registry for Gallstone Surgery and ERCs, GallRiks (n = 215,670), and the Scandinavian Obesity Surgery Registry (SOReg) (n = 60,479) were cross-matched for cholecystectomies with intraoperatively encountered CBD stones in patients with previous RYGB surgery between 2011 and2020. Registry cross-matching found 550 patients. Both LTCBDE (n = 132) and transgastric ERC (n = 145) were comparable in terms of low rates of intraoperative adverse events (1% versus 2%) and postoperative adverse events within 30 days (16% versus 18%). LTCBDE required significantly shorter operating time (P = .005) by on average 31 minutes, 95% confidence interval (CI) [10.3-52.6], and was more often used for smaller stones <4 mm in size (30% versus 17%, P = .010). However, transgastric ERC was more often used in acute surgery (78% versus 63%, P = .006) and for larger stones >8 mm in size (25% versus 8%, P < .001). LTCBDE and transgastric ERC have similarly low complication rates for clearance of intraoperatively encountered CBD stones in RYGB-operated patients, but LTCBDE is faster while transgastric ERC is more often used in conjunction with larger bile duct stones.

Diagnostic accuracy of updated risk assessment criteria and development of novel computational prediction models for patients with suspected choledocholithiasis.

There are risks of choledocholithiasis in symptomatic gallstones, and some surgeons have proposed the identification of choledocholithiasis before cholecystectomy. Our goal was to evaluate the diagnostic accuracy of the latest guidelines and create computational prediction models for the accurate prediction of choledocholithiasis. We retrospectively reviewed symptomatic gallstone patients hospitalized with suspected choledocholithiasis. The diagnostic performance of 2019 and 2010 guidelines of the American Society for Gastrointestinal Endoscopy (ASGE) and 2019 guideline of the European Society of Gastrointestinal Endoscopy (ESGE) in different risks. Lastly, we developed novel prediction models based on the preoperative predictors. A total of 1199 patients were identified and 681 (56.8%) had concurrent choledocholithiasis and were included in the analysis. The specificity of the 2019 ASGE, 2010 ASGE, and 2019 ESGE high-risk criteria was 85.91%, 72.2%, and 88.42%, respectively, and their positive predictive values were 85.5%, 77.4%, and 87.3%, respectively. For Mid-risk patients who followed 2019 ASGE about 61.8% of them did not have CBD stones in our study. On the choice of surgical procedure, laparoscopic cholecystectomy + laparoscopic transcystic common bile duct exploration can be considered the optimal treatment choice for cholecysto-choledocholithiasis instead of Endoscopic Retrograde Cholangio-Pancreatography (ERCP). We build seven machine learning models and an AI diagnosis prediction model (ModelArts). The area under the receiver operating curve of the machine learning models was from 0.77 to 0.81. ModelArts AI model showed predictive accuracy of 0.97, recall of 0.97, precision of 0.971, and F1 score of 0.97, surpassing any other available methods. The 2019 ASGE guideline and 2019 ESGE guideline have demonstrated higher specificity and positive predictive value for high-risk criteria compared to the 2010 ASGE guideline. The excellent diagnostic performance of the new artificial intelligence prediction model may make it a better choice than traditional guidelines for managing patients with suspected choledocholithiasis in future.

Diagnostic performance of laparoscopic transcystic common bile duct exploration for the detection of choledocholithiasis in patients with negative MRCP.

There is little research to evaluate laparoscopic transcystic common bile duct (CBD) exploration (LTCBDE) as a diagnostic test to identify choledocholithiasis undergoing laparoscopic cholecystectomy (LC). This study aimed to assess the technical success and safety of LTCBDE in patients with suspected choledocholithiasis but negative magnetic resonance cholangiopancreatography (MRCP) undergoing LC. We did an ambispective cohort study in patients with gallstones and suspected CBD stones but negative MRCP undergoing LC. The primary outcomes were the rate of complications in the hospital. Between January 2010 and December 2018, 620 patients (median age, 58years; 58.4% female) were eligible for the study. The success rate of LTCBDE was 91.8% and CBD stones were observed in 53.3% with a stone clearance rate of 99.3%. The overall postoperative complication rate was 0.65% and no death was recorded in the total cohort. Notably, the morbidity in LTCBDE is 0.53%. Retained CBD stones were diagnosed in 2 patients and managed by ERCP successfully. In the LTCBDE cohort, the median duration of operation was 78 (60-100) min and the median postoperative hospital stay was 1 (1-2) days. Overall, at a mean follow-up of 4.1 (2.3-6.1) years, recurrent CBD stones occurred in 1.1% and all-cause mortality in 0.6%. LTCBDE should be considered the favored choice in the diagnostic algorithm for patients with suspected choledocholithiasis but negative MRCP undergoing LC.

Laparoscopic Transcystic Common Bile Duct Exploration: 8-Year Experience at a Single Institution

BackgroundLaparoscopic transcystic common bile duct exploration (LTCBDE) is used to treat cholecystolithiasis and choledocholithiasis. This study aimed to investigate the safety, effectiveness and generalisability of LTCBDE in patients with cholecystolithiasis and choledocholithiasis based on our LTCBDE experience within 8 years. MethodsFour hundred patients with cholecystolithiasis and choledocholithiasis (including 62 of cholecystolithiasis and choledocholithiasis with common bile duct no-dilatation) treated with LTCBDE at a single centre from January 2014 to February 2022 were retrospectively evaluated. They were divided into the first 200 and last 200 LTCBDE cases. The disease characteristics, cystic duct incision methods, surgical outcomes and follow-up data were analysed retrospectively. Each patient was followed up for > 3 months. ResultsFour hundred patients underwent LTCBDE, including 188 males and 212 females aged from 15 to 91 years (average age: 56 years). LTCBDE was successful in 377 (94.3%) patients, while treatment was converted to laparoscopic choledocholithotomy with T-tube drainage in 23 (5.8%), owing to intraoperative choledochoscope insertion failure. The CBD diameter (10.89±1.76 vs 9.97 ± 2.39, P < 0.05), cystic duct diameter (4.62±1.03 vs 5.03 ± 1.29, P < 0.05), and operation time (164.60±24.30 vs 135.34 ± 30.00, P < 0.05). Residual stones were found in six (1.5%) patients and removed during the second operation; post-operative bile leakage was found in one (0.3%) patient, who was discharged safely after the second operation. ConclusionsPhase I LTCBDE is safe and effective in treating cholecystolithiasis and choledocholithiasis. With continuous technological advances, LTCBDE has been effectively promoted and applied.

Win or lose, nighttime transcystic laparoscopic common bile duct exploration is a win

ObjectivesAlthough controversial, recent data suggest nighttime versus daytime laparoscopic cholecystectomy (LC) have comparable outcomes. Laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis decreases length of stay (LOS) as compared with...

Sequential transcystic bile duct instrumentation, postoperative results in a high volume center

Background: Cholelithiasis is one of the most common and most demanding gastrointestinal affections regarding hospital expenses. Approximately 10-15% of these patients will present choledocholithiasis. At this moment, there is no general consensus about a therapeutic approach to common bile duct lithiasis. Different experts debate about an one-stage surgical approach (laparoscopic cholecistecomy (LC) and laparoscopic transcystic common bile duct exploration (LTCBDE) compared to a two-staged approach, combining LC and endoscopic retrograde colangio-pancreatography (ERCP).

Tips and Tricks for the Acute Care Surgeon to Perform Laparoscopic Transcystic Common Bile Duct Exploration

Tips and Tricks for the Acute Care Surgeon to Perform Laparoscopic Transcystic Common Bile Duct Exploration

Five-Year Experience with Transcystic Laparoscopic Common Bile Duct Exploration.

Background: Common bile duct (CBD) stones associated with cholecystitis can be treated by single-stage CBD exploration at the time of cholecystectomy or a two-stage approach with endoscopic stone extraction before or after cholecystectomy. The ideal management remains a matter of debate. The aim of this study is to analyze our outcomes with transcystic laparoscopic common bile duct exploration (LCBDE). Material and Methods: A retrospective review of patients who underwent transcystic LCBDE between 2015 and 2019 was performed. Results: A total of 106 patients underwent transcystic LCBDE over 5 years. We performed 1192 laparoscopic cholecystectomies with cholangiograms from March 2015 to December 2019. Fifteen patients had a preoperative endoscopic retrograde cholangiopancreatography (ERCP) for CBD stones seen on magnetic resonance cholangiopancreatography that during laparoscopic cholecystectomy with intraoperative cholangiogram (IOC), there were stones and/or sludge found in the CBD, which required clearance through a transcystic approach. Of the 91 patients who did not have a preoperative ERCP, clearance of the CBD was successful through a transcystic approach in 78 patients (86%). In the 13 patients that intraoperative clearance was not achieved (n = 13, 14%), a postoperative ERCP was performed. A total of 28 patients underwent either pre- or postoperative ERCP (n = 28, 26%). Choledochotomy was not performed in any of the patients. The mean operative time was 127 minutes (127 ± 48). The mean hospital length of stay (LOS) was 4 days (3.9 ± 2.8) with a median LOS of 3 days. Complications observed include wound infection (n = 2, 2%), pancreatitis after ERCP (n = 1, 1%), pneumonia (n = 1, 1%), and right hepatic duct injury (n = 1, 1%). Conclusion: Transcystic LCBDE is an effective and safe option for treatment of CBD stones. While a transcystic approach does not guarantee clearance of the CBD, it avoids the morbidity associated with a choledochotomy and can often prevent patients from having to undergo an additional procedure.

Making common duct exploration common-balloon sphincteroplasty as an adjunct to transcystic laparoscopic common bile duct exploration for pediatric patients

BackgroundLaparoscopic common bile duct exploration (LCBDE) at the time of cholecystectomy has well-established benefits for managing pediatric choledocholithiasis. However, providers increasingly favor ERCP pre-or-post laparoscopic cholecystectomy (ERCP+LC) due to perceived complexity of LCBDE. We refined a stepwise method employing wire-ready balloon dilation of the Sphincter of Oddi. This study compares outcomes of balloon sphincteroplasty (LCBDE+BSP) with standard transcystic LCBDE (LCBDE-STD) and ERCP+LC. MethodsWe performed a retrospective chart review of pediatric patients who underwent LCBDE-STD and LCBDE+BSP since 2018. A report of consecutive choledocholithiasis patients prior to 2018 yielded an ERCP+LC cohort. Age, operative time, complications, and length of stay (LOS) were compared across all groups. Success rate and fluoroscopy time were compared between LCBDE groups. Results44 patients were identified (14:LCBDE-STD; 15:LCBDE+BSP; 15:ERCP+LC) . There was no difference in patient age or BMI. Operative time was longer in the LCBDE+BSP group (p =< 0.05). ERCP+LC demonstrated increased LOS (4.36 ± 2.78 vs 1.31 ± 0.93; p =< 0.05) and complications compared to LCBDE groups including three stent placements and one stent migration. LCBDE+BSP had a higher success rate than LCBDE-STD (100% vs 78%; p = 0.06). The three patients who failed LCBDE-STD required postoperative ERCP. Average fluoroscopy time was not significantly impacted by addition of sphincteroplasty. ConclusionIncorporating LCBDE into standard management of pediatric choledocholithiasis reduces LOS and avoids additional invasive procedures regardless of the specific technique employed. This stepwise approach to wire-ready cholangiography with balloon sphincteroplasty is a viable method for LCBDE that utilizes techniques familiar to pediatric surgeons and provides definitive management under a single anesthetic. Level of evidenceLevel III.

Evaluation of therapeutic efficacy, safety and economy of ERCP and LTCBDE in the treatment of common bile duct stones.

Objectives: This study further compared the endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic transcystic common bile duct exploration (LTCBDE) approaches in the treatment of common bile duct stones (CBDS) from the perspective of efficacy, safety and economy. Methods: The therapeutic efficacy and safety of ERCP and LTCBDE approaches were retrospectively compared. Cost-effectiveness analysis of clinical economics was performed to analyze and evaluate the two approaches. Results: There was no significant difference in the success rate of surgery and bile stone residue between ERCP and LTCBDE group. The incidence of postoperative complications in ERCP group was significantly higher than that in the LTCBDE group; while the incidence of pancreatitis in the ERCP group was significantly higher than that in the LTCBDE group. There was no significant difference in biliary infection, bile leakage and sepsis between ERCP and LTCBDE groups. In terms of cost, the costs of surgery and nursing were significantly lower, the costs of treatment and sanitary materials were significantly higher in the ERCP group than that in the LTCBDE group. There was no significant difference in the costs of medical examination, laboratory test, medicine cost and total cost between ERCP group and LTCBDE group. The total length of hospital stay, length of hospital stay before surgery and duration of surgery in the ERCP group were significantly lower than that in the LTCBDE group; there was no significant difference in length of hospital stay after surgery between the ERCP and LTCBDE group. The cost-effectiveness ratio of ERCP group was 34171.25, and the cost-effectiveness of LTCBDE group was 34524.25. The incremental cost-effectiveness ratio (ICER) of the two groups was 51415. Conclusion: ERCP and LTCBDE approaches had similar therapeutic efficacy in the treatment of CBDS. The safety of LTCBDE approach is superior to that of ERCP approach for the treatment of CBDS. ERCP approach is more economical in the treatment of CBDS than LTCBDE approach.

Microincision of the Cyst Duct Is Safe and Effective for the Failed Laparoscopic Transcystic Common Bile Duct Exploration

Microincision of the Cyst Duct Is Safe and Effective for the Failed Laparoscopic Transcystic Common Bile Duct Exploration

Transcystic Laparoscopic Common Bile Duct Exploration versus Endoscopic Retrograde Cholangiopancreatography in the Management of Choledocholithiasis

Introduction: Choledocholithiasis is present in approximately 10-15% of patients with symptomatic cholelithiasis1. Choledocholithiasis can be managed surgically or endoscopically with endoscopic retrograde cholangiopancreatography (ERCP).

Laparoscopic transcystic common bile duct exploration in patients with a nondilated common bile duct.

Laparoscopic transcystic common bile duct exploration (LTCBDE) is the minimally traumatic surgical method for the treatment of choledocholithiasis secondary to cholecystolithiasis with dilated common bile duct (CBD). However, no report exists concerning LTCBDE in patients with nondilated CBD. The purpose of this study was thus to explore the safety, efficacy, and feasibility of LTCBDE in patients with choledocholithiasis secondary to cholecystolithiasis with nondilatation of the CBD. We retrospectively analyzed 47 patients with choledocholithiasis secondary to cholecystolithiasis who were treated with LTCBDE at the Second Affiliated Hospital of Nanchang University from January 2017 to August 2021 (all the patients had undergone endoscopic retrograde cholangio-pancreatography treatment, but this failed due to various reasons). Clinical data on disease characteristics, methods for cystic duct incision and CBD stone extraction, and surgical outcomes were collected and reviewed. Each patient was followed up for more than 3 months. There were 47 patients in this study, including 21 females and 26 males, with their ages ranging from 15 to 82 years (51±15 years). All patients were treated with surgery, and the CBD stones were removed successfully. Among these patients, 45 underwent LTCBDE for the removal of stones in the CBD, with failure occurring in 2 patients who then accepted laparoscopic common bile duct stone removal (LCBDE) + T tube drainage. The diameter of the cystic duct was 0.30-0.73 cm (0.60±0.07 cm), the diameter of the CBD was 0.60-0.80 cm (0.73±0.05 cm), the operation time was 75-220 minutes (159±33 minutes), and the postoperative hospital stay was 2-13 days (6±2 days). None of the patients experience any serious postoperative complications, and all were discharged safely. During the follow-up, no postoperative biliary stenosis, bile leakage, or other complications occurred. LTCBDE is feasible to treat patients with choledocholithiasis secondary to cholecystolithiasis with nondilatation of the CBD. This choice of treatment plan reduces the length of hospital stay and the occurrence of postoperative complications. However, it is recommended that this be attempted on the basis of the experience of LTCBDE with dilated CBD.

Surgical methods of treatment for cholecystolithiasis combined with choledocholithiasis: six years’ experience of a single institution

IntroductionThe optimal treatment of choledocholithiasis combined with cholecystolithiasis remains controversial. Common surgical methods vary among endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC), laparoscopic transcystic common bile duct exploration (LTCBDE), laparoscopic transductal common bile duct exploration (LCBDE) with or without T-tube drainage. The purpose of this study is to evaluate the safety and effectiveness of surgical methods and to determine the appropriate procedure for patients with cholecystolithiasis combined with choledocholithiasis.MethodsFrom January 2013 to January 2019, a total of 1555 consecutive patients diagnosed with cholecystolithiasis combined with choledocholithiasis who underwent surgical treatment in Tongji Hospital were retrospectively analyzed. Total 521 patients with intrahepatic bile duct stones underwent LC + LCBDE + T-Tube were excluded from the analysis. At last, 1034 patients who met the inclusion criteria were divided into three groups according to their surgical methods: preoperative ERCP + subsequent LC (ERCP + LC group, n = 275), LC + LCBDE + intraoperative endoscopic nasobiliary drainage (ENBD) + primary duct closure (Tri-scope group, n = 479) and LC + laparoscopic transcystic CBD exploration (LTCBDE group, n = 280). Clinical records, operative findings and postoperative follow-up were collected and analyzed.ResultsThere was no mortality in three groups. Common bile duct (CBD) stone clearance rate was 97.5% in ERCP + LC group, 98.7% in Tri-scope group, and 99.3% in LTCBDE group. There were no difference in terms of demographic characteristics, biochemistry findings and presentations, but the Tri-scope group had the biggest diameter and amount of stones and diameter of CBD, the LTCBDE group had the least CBD stones and the biggest diameter of cystic gall duct (CGD). ERCP + LC group have the longest hospital stay (14.16 ± 3.88 days vs 6.92 ± 1.71 days vs 10.74 ± 5.30 days, P < 0.05), also has the longest operative time than others (126.08 ± 42.79 min vs 92.31 ± 10.26 min, 99.09 ± 8.46 min, P < 0.05). Compared to ERCP + LC group, LTCBDE group and Tri-scope group had lower postoperation-leukocyte, shorter surgery duration and hospital stay (P < 0.05). Compared to the Tri-scope group, the LTCBDE group had the shorter hospital stay, extubation time and operation time and less intraoperative bleeding. There were less postoperative complications in LTCBDE group (1.1%) compared to the ERCP + LC group (3.6%) and Tri-scope group (2.2%). Follow-up time was 6 to 72 months. Four patients in ERCP + LC group and 5 in Tri-scope group reported recurrent stones.ConclusionAll the three surgical methods are safe and effective. Tri-scope approach and LTCBDE approach have superiority to preoperative ERCP + LC. LC + LTCBDE shows priority over Tri-scope approach, but should be performed in selected patients. LC + LCBDE + T-Tube can be an alternative management if the other three procedures were failed. The surgeons should choose the most appropriate surgical procedure according to the preoperative examination results and intraoperative situation.

Microincision of the cyst duct is safe and effective for the failed laparoscopic transcystic common bile duct exploration

Microincision of the cystic duct and its confluence part, which facilitated the application of transcystic-laparoscopic common bile duct (CBD) exploration (transcystic-LCBDE), had been described in some reports. However, it is unclear whether transcystic-LCBDE with microincision (micro-LCBDE) is effective and safe as transductal-LCBDE for the failed transcystic-LCBDE in patients with choledocholithiasis. In this retrospective cohort study, we assigned patients with cholecystocholedocholithiasis to undergo transcystic-LCBDE and laparoscopic cholecystectomy. The clinical outcomes of one-to-one propensity-matched pairs of Micro-LCBDE and transductal-LCBDE groups were compared. Between January 2007 and December 2018, 1650 patients with confirmed choledocholithiasis attempted transcystic-LCBDE. Micro-LCBDE was done successfully in 128 patients (7.8%) and transductal-LCBDE in 69 patients (4.2%). By one-to-one propensity score matching, 68 pairs were selected. There was no significant difference in in-hospital complication rate: 8.8% in micro-LCBDE group and 11.8% in transductal-LCBDE group (p = 0.573). The duration of operation in micro-LCBDE was a little shorter than that in transductal-LCBDE: median 125 (interquartile range 95-173) versus 150 (120-195) min respectively (p = 0.003). Postoperative recovery was faster in micro-LCBDE than in transductal-LCBDE, as reflected by a shorter postoperative hospital stay (median 3 versus 5 days, p = 0.002, respectively). There was also no significant difference in rates of retained stone and recurrence of CBD stone between the groups. Our findings suggest that micro-LCBDE surgery was effective and safe as transductal-LCBDE surgery in patients with failed transcystic-LCBDE, suggesting that the micro-LCBDE is an acceptable alternative to transductal-LCBDE for failed transcystic-LCBDE.

16 Re-Do of Laparoscopic CBD Exploration Through Cystic Duct Remnant Following Laparoscopic Cholecystectomy; A Case Series

Abstract Introduction Common bile duct (CBD) stones are detected in approximately 10-15% of patients with gallstone disease. They can be formed in the absence of gallbladder stones or in patients who underwent previous cholecystectomy. Laparoscopic common bile duct exploration has been documented since 1999, with increasing evidence illustrating the effectiveness of the transcystic approach. There is no review of re-exploration of the CBD, due to retained stones, following laparoscopic cholecystectomy (LC) via this approach. Four cases are presented detailing need for initial intervention, and intra-operative findings. Method Review of four cases in 2020 in Aberdeen Royal Infirmary. Each underwent re-do laparoscopic transcystic common bile duct exploration for retained stone, following previous laparoscopic cholecystectomy. Results Each case had successful stone clearance and resolution of symptoms. Conclusions With increasing laparoscopic technology and surgical skill, re-exploration of the CBD following previous LC due to emergency surgical presentations should be performed. This is feasible and safe. We recommend the transcystic approach due to reduced morbidity and high success rates of stone extraction.

Porcine Aorto-Renal Artery (PARA) model for laparoscopic transcystic common bile duct exploration: the evolution of a training model to meet new clinical needs

BackgroundThe transcystic approach to laparoscopic common bile duct exploration has gained popularity for the single-stage management of choledocholithiasis with concomitant gallstones. Our team previously described the use of a porcine aorta segment to simulate the common bile duct during laparoscopic skill training.MethodsWith the advent of the transcystic approach as a contender for the first-line technique of accessing the common bile duct, we present an evolution of the laparoscopic training model using a Porcine Aorta-Renal Artery (PARA) specimen to simulate the structural integrity, dimensions and spatial distribution of both the human cystic and common bile ducts.ResultsThis training model allows the use of a choledochoscope for transcystic exploration of the biliary tree. It combines fidelity and reproducibility required for a simulated training model to offer experience in laparoscopic transcystic common bile duct exploration. Validation of the model was demonstrated by 21 surgeons who completed a questionnaire after performing the simulated procedure. In all sections assessing reliability, face validity and content validity of the model, mean rating scores were between 4 and 5 out of five (good or excellent).ConclusionsWe present the evolution of an established training model for laparoscopic common bile duct exploration which focusses the attention on the transcystic approach to the common bile duct and the use of lithotripsy techniques. The need for such a model reflects the shift in the current practice of the laparoendoscopic management of choledocholithiasis with concomitant gallstones from transductal to transcystic approach.