Laparoscopic Transcystic Common Bile Duct Research Articles

A novel laparoscopic transcystic approach using an ultrathin choledochoscope and holmium laser lithotripsy in the management of cholecystocholedocholithiasis: An appraisal of their safety and efficacy

BackgroundAlthough laparoscopic transcystic common bile duct exploration (LTCBDE) is the preferred approach for CBD stone clearance, the success rate can vary between 55% and 85%. This study evaluated if ultrathin choledochoscope and holmium laser lithotripsy could improve the success rate of LTCBDE. MethodsRecords of 126 patients (average age, 46.1 ± 13.8 years) with cholecystocholedocholithiasis treated with laparoscopic cholecystectomy (LC) and LTCBDE were retrospectively reviewed. ResultsLC+LTCBDE was performed successfully in 118 of 126 patients, with a surgical success rate of 93.7%. An ultrathin choledochoscope was used in 75 (63.5%) patients, and holmium lithotripsy was performed in 38 (32.2%) patients. The stone clearance rate was 99.2% (117/118). No significant complications occurred. One hundred (84.7%) patients had excellent and 13 (11%) had good outcomes for an overall success rate (excellent plus good) of 95.7%. ConclusionUltrathin choledochoscope and holmium laser lithotripsy can improve the surgical outcomes of LC+LTCBDE with minimal complications.

Gangrenous cholecystitis: innovative laparoscopic techniques to facilitate subtotal fenestrating cholecystectomy when a critical view of safety cannot be achieved.

Gangrenous cholecystitis is associated with a higher conversion rate of conversion from laparoscopic to open than acute non-gangrenous cholecystitis. New strategies and techniques are needed to decrease conversion rates and improve outcomes. In this article, we provide a richly detailed, illustrated description of a modified fundus-first technique that we have developed over the last 15years and now use routinely with rare conversions. We also compared outcomes of laparoscopic (LC) and open (OC) approaches for pathologically confirmed gangrenous cholecystitis in 146 patients during 1995-2005, the first 10years during which these two approaches were performed contemporaneously at our institution on comparable patients. Among the 142 patients that met the inclusion criteria, laparoscopic procedures were started in 112 (79%) of these patients, with successful completion in 72 resulting in an overall conversion rate of 36%. During the last 5years, however, in cases where the described laparoscopic technique was used, no patient has required conversion. The laparoscopic LC group had shorter average ICU stay (p<0.05) and overall length of stay (2 vs 6days, p<0.001). Intraoperative cholangiography was completed in 37 of 72 LC patients (52%) versus 6 of 30 OC (20%). In five of the LC patients, a filling defect was seen on the cholangiogram and laparoscopic transcystic common bile duct stones, thereby avoiding a second anesthetic and endoscopic procedure. In the setting of severe inflammation, a number of procedural modifications can be incorporated to allow the surgeon to approach dissection of the gangrenous gallbladder using a flexible operative plan designed to optimize safe completion of this challenging procedure, with the expected improvement in surgical outcomes.

What Should We Do for the Failed Laparoscopic Transcystic Common Bile Duct Exploration

What Should We Do for the Failed Laparoscopic Transcystic Common Bile Duct Exploration

Ultrathin choledochoscope improves outcomes in the treatment of gallstones and suspected choledocholithiasis

ABSTRACTBackground: We aimed to compare laparoscopic cholecystectomy (LC) and simultaneous laparoscopic transcystic common bile duct exploration (LTCBDE) using an ultrathin choledochoscope with LC followed by endoscopic retrograde cholangiopancreatography (ERC) and endoscopic sphincterotomy (ES) when indicated.Methods: We retrospectively reviewed the records of patients seen between 2004 and 2014 and treated with LC+LTCBDE or LC for gallstones and suspected choledocholithiasis. Postoperative complications and surgical outcomes were compared using t-test, Mann-Whitney U test, or chi-square test.Results: 115 patients underwent successful LC+LTCBDE and 112 LC; follow-up data was available for 103 and 106 patients, respectively. Seventeen patients (16.5%) in the LC+LTCBDE group and 10 (28.6%) in the LC+ERC+ES group developed complications (P = 0.114). The LC+LTCBDE group had a significantly higher rate of satisfactory biliary function outcomes than the LC+ERC+ES group (98.1% vs. 85.7%, respectively) (P = 0.017).Conclusions: Single-step LC+LTCBDE using an ultrathin choledochoscope may provide better outcomes in patients with gallstones and suspected choledocholithiasis.

Laparoscopic Transcystic Common Bile Duct Exploration in the Elderly is as Effective and Safe as in Younger Patients.

Choledocholithiasis represents a greater proportion of gallstone in the elderly. Elderly patients have more comorbidity, which could increase the operative risk and postoperative complications. However, no study has focused on the effect and safety of laparoscopic transcystic common bile duct exploration (LTCBDE) in elderly patients. The aim of this study was to investigate whether LTCBDE can be performed effectively and safely in elderly patients. This is a retrospective study of patients who underwent LTCBDE for choledocholithiasis performed from January 2010 to December 2012. Patients of age 70 or older were included in the elderly group. The rest integrated the younger group. Demographic data and perioperative parameters were compared between groups. From January 2010 to December 2012, 171 patients admitted for choledocholithiasis and gallstone attempted a single-step treatment combining LTCBDE and laparoscopic cholecystectomy. There were 104 women (60.8%) and 67 men (39.2%) with a median age of 57 (range 24-87) years. Elderly patients had significantly more preoperative risk factors. However, there was no significant difference in the success rate of LTCBDE (96.9% versus 92.7%, P = .142) for the two groups. The operative time was a little longer in elderly group than in younger group: median 80 (60-110) minutes versus 70 (50-95) minutes, respectively (P < .001). Postoperative recovery was slower in elderly group than in younger group, as reflected by a longer median postoperative hospital stay (2 days versus 1 day, P < .001) and a higher rate of abdominal drain placed (17.1% versus 8.5%, P = .202). The rates of postoperative complications at discharge were similar between groups (3.0% versus 4.9%, P = .952). LTCBDE in the elderly patients is as effective and safe as in younger patients.

Laparoscopic Transcystic Common Bile Duct Exploration: T-Shaped Incision of Cystic Duct with FREDDY Laser Lithotripsy.

Optimal laparoscopic techniques for management of gallstones concomitant with common bile duct (CBD) stones remain under debate. The aim of this study was to evaluate a novel approach to managing gallstones concomitant with large or impacted CBD stones through a modified laparoscopic transcystic CBD exploration (LTCBDE) with frequency-doubled double-pulse neodymium:YAG (FREDDY) laser lithotripsy. This retrospective review includes 32 consecutive patients with gallstones concomitant with large or impacted CBD stones who were offered LTCBDE with FREDDY laser lithotripsy between June 2012 and December 2014. Demographic, perioperative, and follow-up data were collected and analyzed retrospectively. CBD stone clearance was achieved for all patients. There were 13 males and 19 females, among whom there were three patients with a history of abdominal surgery. The diameter of the CBD ranged from 10 to 20 (mean 15.1) mm, and the number of CBD stones ranged from 1 to 5. CBD stones ranged in diameter from 9 to 18 (mean 11.7) mm and 9 patients had stones that were impacted in the CBD. The mean operative time was 123 ± 18 minutes with a range of 72 to 155 minutes. The mean length of postoperative hospital stay was 5.3 (range 4-7) days. All patients recovered normally without morbidity or mortality. The modified LTCBDE with a T-shaped incision of the cystic duct and FREDDY laser lithotripsy is a safe and effective means of managing gallstones concomitant with large or impacted CBD stones.

Laparoscopic transcystic common bile duct exploration with stone extraction

Laparoscopic transcystic common bile duct exploration with stone extraction

Total laparoscopic versus endolaparoscopic common bile duct stone extraction and cholecystectomy

Background Endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy (LC) was the traditional method for the treatment of common bile duct (CBD) stones associated with gall bladder (GB) stones. With advances in laparoscopic instrumentation and skills, totally laparoscopic transcystic common bile duct exploration is technically feasible and increasingly practiced by surgeons worldwide. Objective The aim of this study was to compare the results of the two procedures in the management of CBD stones associated with GB stones. Patients and methods A prospective randomized clinical study was carried out from December 2010 to December 2015. It included 252 patients with concomitant GB stones and CBD stones who were divided into two groups: group A (126 patients) included patients who underwent laparoscopic transcystic common bile duct exploration and stone extraction with LC in one stage, and group B (126 patients) included patients who underwent endoscopic retrograde cholangiopancreatography for CBD stone extraction followed by LC after 2–3 days in two stages. Patients were followed up postoperatively at 1 week, 1, 6 months, and 1 year. Results The success rate was similar in groups A and B (88.1% in group A vs. 80.2% in group B; P = 0.2). The average number of procedures per patient was significantly lower in group A ( P P P = 0.6). On the first day after surgery, the pain score was lower in group A ( P = 0.03). Hospital stay of group A patients was significantly shorter ( P = 0.03). The cost of treatment per patient in group A was significantly lower ( P = 0.001). The patients in group A had higher satisfaction scores ( P = 0.006). Conclusion Although both approaches have equivalent success rates, the one-stage approach is better in terms of shorter hospital stay, fewer procedures, and better satisfaction and cost-effectiveness compared with the two-stage approach. Our study suggests that one-stage management is the treatment of choice for patients with concomitant GB and CBD stones.

Laparoscopic Transcystic Treatment Biliary Calculi by Laser Lithotripsy.

Background and Objectives:Laparoscopic transcystic common bile duct exploration (LTCBDE) is a complex procedure requiring expertise in laparoscopic and choledochoscopic skills. The purpose of this study was to investigate the safety and feasibility of treating biliary calculi through laparoscopic transcystic exploration of the CBD via an ultrathin choledochoscope combined with dual-frequency laser lithotripsy.Methods:From August 2011 through September 2014, 89 patients at our hospital were treated for cholecystolithiasis with biliary calculi. Patients underwent laparoscopic cholecystectomy and exploration of the CBD via the cystic duct and the choledochoscope instrument channel. A dual-band, dual-pulse laser lithotripsy system was used to destroy the calculi. Two intermittent laser emissions (intensity, 0.12 J; pulse width 1.2 μs; and pulse frequency, 10 Hz) were applied during each contact with the calculi. The stones were washed out by water injection or removed by a stone-retrieval basket.Results:Biliary calculi were removed in 1 treatment in all 89 patients. No biliary tract injury or bile leakage was observed. Follow-up examination with type-B ultrasonography or magnetic resonance cholangiopancreatography 3 months after surgery revealed no instances of retained-calculi–related biliary tract stenosis.Conclusion:The combined use of laparoscopic transcystic CBD exploration by ultrathin choledochoscopy and dual-frequency laser lithotripsy offers an accurate, convenient, safe, effective method of treating biliary calculi.

Learning curve and outcome of laparoscopic transcystic common bile duct exploration for choledocholithiasis.

The best approach for cholecystocholedocholithiasis remains a matter of debate. The aim of this study was to evaluate the technical aspects, learning curve and outcome of laparoscopic transcystic common bile duct exploration (LTCBDE). Patients who underwent laparoscopic cholecystectomy with LTCBDE between January 2007 and December 2012 were identified from an institutional database. Data on preoperative investigations, intraoperative and postoperative findings were retrieved retrospectively from the patients' hospital notes. There were 399 women (56·4 per cent) and 309 men (43·6 per cent), with a median age of 58 (range 18-87) years. Microincision (incision of the cystic duct at the confluence with the common bile duct (CBD) with extension of only 3-5 mm at the lateral margin of the CBD) and lithotripsy were used in the transcystic exploration in 119 patients, and increased the success rate of LTCBDE from 74·2 to 91·0 per cent. The median duration of operation was 85 (i.q.r. 65-120) min and the median postoperative hospital stay was 2 (1-3) days. Retained common bile duct stones were observed in 13 patients, and postoperative complications developed in 27 patients. The cumulative sum duration of operation learning curve comprised two phases; phase 1 included the first 250 patients and phase 2 the remaining 458 patients. Duration of operation and postoperative hospital stay decreased with increasing volume per surgeon. Recurrence of common bile duct stones was diagnosed in 26 patients during a median follow-up of 4 years. LTCBDE with or without microincision and/or lithotripsy is a safe and effective approach.

Laparoscopic transcystic laser lithotripsy for common bile duct stone clearance.

Laparoscopic transcystic common bile duct (CBD) exploration is a safe single-stage procedure for CBD stone clearance. The aim of this report was to describe our experience of transcystic laser lithotripsy in patients with complex CBD stones. Data from consecutive patients treated with transcystic holmium:YAG laser lithotripsy was collected and analyzed concerning age, sex, number of stones, duct clearance, conversions, operation time, complications, and hospital stay. Duct clearance was achieved in all (n=8) patients as a single-stage procedure, although 1 had to be converted to open surgery. Median operation time was 225 minutes and hospital stay was 2 days. There was no postoperative morbidity or mortality. Laparoscopic transcystic use of holmium:YAG laser for complex CBD stones seems safe and efficient even though operation time is long. The technique has the potential of completing the treatment armamentarium for transcystic laparoscopic clearance of difficult CBD stones.

Laparoscopic transcystic common bile duct exploration in the management of choledocholithiasis

Background: Common bile duct (CBD) stones are identified in 10-15% of patients undergoing surgery for symptomatic cholelithiasis. When choledocholithiasis is suspected preoperatively, it is recommended that endoscopic retrograde cholangiography (ERC) be performed, and if the choledocholithiasis is confirmed, the patient should then undergo endoscopic sphincterotomy (ES). When CBD stones are discovered intraoperatively, the surgeon proceeds with laparoscopic common bile duct exploration (LCBDE), converts the case to open CBD exploration and choledocholithotomy, or leaves the stones in place for postoperative ES and stone extraction. We report here our initial results oflaparoscopic transcystic CBD exploration (LTCBDE) in the management of patients with choledocholithiasis. Patients and methods: From October 2009 to June 2012, we performed 320 laparoscopic cholecystectomies for symptomatic gallstone disease at Zagazig University Hospitals. In the present study, intraoperative cholangiography (IOC) was performed in 47 out of 320 (14.7%) patients. It was negative in 5 (10.6%) patients and suggestive ofCBD stones in 42 (89.4%) patients. The incidence of choledocholithiasis in our study was 13.12% (42 from 320 patients). Three patients were converted to open surgery directly when CBD stones were detected, and two patients were referred for postoperative ERCP. Laparoscopic CBD exploration (LCBDE) was attempted in 37 patients. In 7 patients laparoscopic choledochotomy was done. In the remaining 30 patients (71.4%) LTCBDE was performed. Results: LTCBDE was successful in 27 out of 30 patients (90%). In three patients, LTCBDE failed and were converted to open surgery. Causes of failure of TCBDE were numerous stones (> 8) in one patient, impacted stones at distal CBD in another patient and intrahepatic displacement of stones in the third patient. The mean operative time was 110 ± 30 minutes. Postoperative complications included pulmonary atelectasis in two elderly patients, deep vein thrombosis in one patient and ileus in one patient. The overall complication rate was 13.3%. There were no deaths. No bile leak was observed in any of our patients and all were discharged within the first 48 hours. The mean recovery time was 8 days (ranging from 7 to 10 days). Time to return to full physical activity was 14±4 days.Fallow-up for 6 months to 2 years was possible in 26 patients (86.7%), and no residual stones were found in any ofthem. Conclusion: CBD stones still occur in about 10-15% ofpatients undergoing LC. 90% of these patients could be treated successfully using LTCBDE, with no increase in morbidity or mortality; it seems reasonable to remove stones during the laparoscopic procedure to avoid the possibility of postoperative ERCP or conversion to open surgery. The complications, length of hospital stay, and recovery time were similar to outcomes in patients who underwent LC only. We found that multiple or impacted stones are risk factors for conversion to open surgery. The benefits attained by minimally invasive surgery confirm that LTCBDE should become the primary strategy in the vast majority of patients harboring common bile duct stones.

Short-Term Outcomes of Laparoscopic Transcystic Common Bile Duct Exploration with Discharge Less Than 24 Hours

Reducing the length of stay and discharge time for patients could benefit multiple hospital units by saving money, reducing waiting time, and providing the opportunity for more patients to be treated. However, no experience of laparoscopic transcystic common bile duct exploration (LTCBDE) with discharge less than 24 hours has been reported until now. The objective of this study was to assess the feasibility and safety of LTCBDE with discharge less than 24 hours. A retrospective review showed that 34 of 111 patients scheduled in our institution were discharged less than 24 hours after LTCBDE between June 1 and December 31, 2011. A multimodal approach including appropriate preoperative assessment, education and counseling, early postoperative oral intake, and early mobilization was carried out. Outcomes were analyzed for patient demographics, postoperative stay, operation time, intraoperative bleeding, and reasons for failed LTCBDE. Of 111 patients admitted for LTCBDE, 34 patients were discharged within 24 hours postoperatively. This study population comprised 11 males and 23 females with a mean age of 54.6±14.7 years (range, 28-79 years). The mean postoperative stay was 20.21±0.39 hours. There were no postoperative complications or deaths during the hospital stay or at the follow-up 12 months postoperatively in these 34 patients. LTCBDE with discharge less than 24 hours is feasible and safe in selected patients with common bile duct stones of no more than three in number and no more than 6 mm in size. The benefit of the multimodal approach and LTCBDE may be synergistic, allowing a quick recovery of gastrointestinal function.

Transcystic Approach with Micro-incision of the Cystic Duct and Its Confluence Part in Laparoscopic Common Bile Duct Exploration

Laparoscopic transcystic common bile duct exploration has become a safe and ideal treatment of common bile duct stones. This study was designed to explore the clinical value of modified laparoscopic transcystic common bile duct exploration as a first line of treatment for patients with common bile duct stones. A retrospective, case-control study of clinically comparable groups of patients who underwent the laparoscopic transcystic approach with micro-incision of the cystic duct and its confluence part in common bile duct exploration (LTM-CBD) (n=110) and laparoscopic common bile duct exploration (LCBD) (n=100) under the care of one surgeon was performed. All clinical data were analyzed retrospectively. There was no significant difference in terms of operation time between the two groups (P>.05). Postoperative hospital stay and abdominal drainage time were shorter in the LTM-CBD group than in the LCBD group (P<.05). Postoperative bile leakage was seen in 1 case (1 of 110) in the LTM-CBD group and 10 cases (10 of 100) in the LCBD group (P<.05). Twenty patients underwent T-tube drainage in the LCBD group, and primary closure was performed in the other patients; however, all cases in the LTM-CBD group underwent primary closure. The median follow-up was 12 months; 2 patients in the LCBD group who suffered from bile leakage presented with obstructive jaundice due to bile duct stenosis 6 months postoperatively. LTM-CBD, which can avoid postoperative T-tube drainage, decrease complications, shorten hospitalization time, and enhance the existing quality, is a minimally invasive, safe, and effective treatment.

Laparoscopic cholecystectomy and laparoscopic transcystic common bile duct exploration using a mini incision and primary suturing of the bile duct in the treatment of gallbladder and common bile duct stones

Objective To study the results of laparoscopic approach in the treatment ot gallbladder and common bile duct stones.Method The authors reviewed data of 60 patients with gallbladder and bile duct stones treated laparoscopically.Results All the 60 patients treated with laparoscopic cholecystectomy and laparoscopic transcystic common bile duct exploration (LcTDE) were successful.There were 1 bile duct stone in 32 patients,and 2 to 6 bile duct stones in 28 patients.The operation time was (38.7±15.1) min and the hospitalization time was (5.5±2.1) days.One patient developed biliary fistula postoperatively which healed after 7 days of conservative treatment.One patient had bile duct residual stone which was treated by ERCP.The remaining patients were well.Conclusion Laparoscopic transcystic common bile duct exploration using a mini incision and primary suturing of the bile duct was simple,safe and efficacious. Key words: Cholelithiasis; Biliary tract surgical procedures; Laparoscopes

Application of electrohydraulic lithotripsy combined with choledochoscopy in laparoscopic transcystic common bile duct exploration

Application of electrohydraulic lithotripsy combined with choledochoscopy in laparoscopic transcystic common bile duct exploration

Intrahepatic choledochoscopy during trans-cystic common bile duct exploration; technique, feasibility and value

Transcystic laparoscopic common bile duct exploration (TC-LCBDE) is advantageous for exploring the bile duct. Choledochoscopy, however, may be quite challenging to perform transcystically because the cystic duct is usually narrow, duct anatomy may be unfavorable, and not all stones are amenable to transcystic extraction. Convention suggests that it is technically very difficult to visualize the intrahepatic bile ducts with transcystic choledochoscopy, due to the angle of insertion of the cystic into the common bile duct (CBD). However, we have performed intrahepatic choledochoscopy successfully, moving the choledochoscope from the CBD into the common hepatic duct by using what we have termed a "wiper blade maneuver". The purpose of this study was to confirm how often this was possible. A search of a prospectively collected database of patients undergoing routine intraoperative cholangiography (IOC) and laparoscopic CBD exploration under the care of a single consultant surgeon was performed. A total of 592 LCBDEs were performed between September 1992 and January 2011; 325 were transcystic explorations. Of these, 72.5 % were female and 56 % were admitted acutely. Exploration and duct clearance was performed by blind Dormia basket trawling in 63 %. The choledochoscope was utilized in 120 cases (37 %). The 3-mm choledochoscope was used in 66 (55 %) and the 5-mm scope in 54 (45 %). Intrahepatic choledochoscopy was performed in 49 patients (40.8 %). Length of surgery was 40-350 min (median 90 min; standard deviation 49 min). It is technically challenging to perform intrahepatic choledochoscopy with a 3-mm choledochoscope due to its narrow gauge. The more rigid 5-mm scope is thus preferred, but is limited in TCE because its effective use depends on the presence of a dilated cystic duct. Despite the technical limitations of both caliber scopes, we have demonstrated that intrahepatic choledochoscopy during TCE is possible, with each, in 40 % of cases.

Complications after bile duct exploration for secondary choledocholithiasis using a combined laparoscopic and choledochoscopic approach

Objective To study the complications after laparoscopic bile duct exploration.Methods Two approaches for bile duct exploration were used in 105 patients: (1) laparoscopic transcystic common bile duct exploration (LTCBDE) was used for patients with gallstones with choledocholithiasis and cystic duct dilation. No T tube was used for drainage, (2) Laparoscopic common bile duct exploration (LCBDE) was used for patients with gallstones with choledocholithiasis but without cystic duct dilation. The common bile duct was sutured primarily without T tube drainage in those patients with a small number of stones. T tube drainage was used in those patients with many stones or severe edema at the lower end of the common bile duct. Results We carried out LTCBDE+ LC in 70 patients and LCBDE+LC in 35 patients, 14 patients had T tube drainage and 21 patients had no T tubes in the latter group of patients. Postoperatively, there were ascites in 17 patients (LTCBDE 6 and LCBDE 11 ), biliary peritonitis in 5 patients (1 LTCBDE and 4 LCBDE), abdominal pain in 13 patients (LTCBDE 4 and LCBDE 9), and fever in 11 patients (LTCBD 3 and LCBDE 8). All the complications responded to conservative treatment. 14 patients in the LCBDE group had residual stones.Choledochoscopy was used to remove the residual stones. There was no pancreatitis. Conclusions Adequate preoperative workup, good clinical judgment and precise treatment skill help to reduce complication rates after operation for gallstones with choledocholithiasis. Key words: Gallstones; Secondary choledocholithiasis; Minimal invasive methods

Laparoscopic common bile duct exploration and holmium laser lithotripsy: a novel approach to the management of common bile duct stones

Endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic common bile duct exploration (LCBDE) have proved to be safe and effective ways of managing common bile duct (CBD) stones. Clearance of large or impacted CBD stones by routine endoscopic maneuvers can be challenging, often requiring more invasive techniques such as open CBD exploration, which increases morbidity. This report presents a novel approach to managing impacted CBD stones using laparoscopic transcystic common bile duct exploration and holmium laser lithotripsy with favorable outcomes. This retrospective review analyzes five patients who underwent laparoscopic cholecystectomy with intraoperative management of impacted CBD stones via LCBDE and holmium laser lithotripsy. The technique is described, and outcomes are measured. Data via chart review and use of intraoperative video were obtained with institutional review board approval. Stone clearance from the CBD was achieved for all the patients. The median age of the patients was 39 years. The diameters of the CBDs ranged from 10 to 20 mm, and the median number of stones was one. No mortality was associated with this procedure, and the median hospital stay was 2 days. Laparoscopic CBD exploration via a transcystic approach together with holmium laser lithotripsy is a safe and effective way to clear large solitary or impacted CBD stones. This technique also avoids choledochotomy and may be used in concert with other methods such as ERCP, percutaneous cholangioscopy, and open exploration.

Why is there recurrence after transcystic laparoscopic bile duct clearance? Risk factor analysis

Incidence of common bile duct stones (CBDS) is approximately 10% in patients with symptomatic gallstones undergoing laparoscopic cholecystectomy. Transcystic laparoscopic common bile duct exploration (TC-CBDE) is safe and efficient in achieving bile duct clearance from stones, with a success rate of between 85% and 95%. The aim of this retrospective study is the evaluation of risk factors and recurrence in patients treated with TC-CBDS. From October 2003 until September 2007, 110 consecutive patients with common bile duct stones and gallbladder were included in the study. Average age was 64 years (range 21-82 years). The procedure was completed laparoscopically in 106 patients (96.4%): with TC-CBDE in 90 patients (85%), who are the object of this study; and with TC-CBDE + perioperative guide wire papillotomy ("rendezvous") in 16 cases (15%). In the 90 patients treated with TC-CBDE which we examined, the risk factors were: preoperative liver function tests, diameter of the common bile duct (normal 8 mm or less), number of stones (<or=3 or more), presence of stones with biliary sludge, and pre- or intraoperative diagnosis. Student's test was used for statistical analysis with a P value of < 0.05 defined as statistically significant. The conversion rate to open surgery was 3.6%. There were no mortalities. The average operative time was 115.6 min. The morbility rate was 7.7% with 4.8% local complications and 2.9% general complications. Average follow-up on 90 patients (after TC-CBDE) was 28 months (range 4.2-48 months). We found six recurrences (6.7%). The statistic analysis showed that only number of stones >3 with biliary sludge predicted a recurrence (p < 0.05) while the other factors did not show important clinical variables. TC-CBDE is safe and effective in the majority of cases of CBDS. The incidence of recurrence is low but there are some risk factors, such as number of stones >3 with biliary sludge, which do not favor the successful outcome of the procedure. In such cases, it is essential that the TC-CBDE is integrated with other procedures which, although more complex, assure the clearance of the bile duct.