Transcystic Clearance Research Articles

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

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

How to choose the most appropriate technique for the single-stage treatment of cholecysto-choledocolithiasis?

BackgroundWe utilized transcystic clearance and intra-operative papillotomy through a rendezvous technique for the treatment of cholecysto-choledocolithiasis. The goal of this study was to evaluate the reliability of pre-operative parameters to address the most suitable surgical procedure.MethodsA total of 180 patients affected by calculi of the gallbladder and bile duct underwent the single-stage treatment. According to several pre-operative parameters, 141 patients had to supposedly undergo transcystic clearance of the bile duct, while 39 patients had to be treated with the rendezvous technique. All patients were treated with the sequential procedure: first, we tried the transcystic procedure and, if there was a failure, we used a rendezvous technique. We prospectively analysed each group based on a series of variables such as sex, age, operative time, success rate of proposed treatment, conversion rate, post-operative complications and hospital stay.ResultsTranscystic clearance was successful in 134 out of 141 patients (95.0%), while 2 patients needed to undergo a laparo-endoscopy procedure (failure). Thirty-five out of 39 patients (89.7%) obtained common bile-duct (CBD) clearance through the rendezvous technique, while 1 patient obtained clean-up through the simple transcystic procedure (failure). Five out of 141 patients with transcystic clearance and 3 out of 39 patients with the rendezvous technique underwent laparotomy CBD clearance with conversion rates of 3.5% and 7.7%, respectively. Post-operative complications showed similar percentages for both procedures. However, the surgical time turned out to be longer for the rendezvous technique.ConclusionsThe one-stage procedure for the treatment of cholecysto-choledocolithiasis was possible in 94% of the cases utilizing a surgical technique selected according to the patient’s case history. The pre-operative parameters, such as jaundice, CBD diameters and stone diameters, have certified their reliability as good predictors of the most suitable procedure to follow.

The Optimal Choice to 1 Stage Procedure for the Treatment of Cholecysto-choledocholithiasis

Introduction: The one-stage procedure for the treatment of cholecysto-choledocolithiasis turns out to be optimal in terms of reduction of costs and patient's compliance. We utilized trans-cystic clearance and intra-operative papillotomy through rendez-vous technique. There still lacks a procedure conform to every case, hence it would be appropriate to know preliminarily the best procedure for each specific patient. The goal of this study was to evaluate the reliability of pre-operative parameters to address the most suitable surgical procedure. Methods: From January 2008 to December 2015, we observed 1818 patients affected by gallbladder stones; among these, 186 (10.5%) were also affected by calculi of the bile duct. 180 consecutive patients underwent the single stage treatment. The group was composed of 102 women and 78 men and the average age was 53 years old (32-77). Patients were divided into two different groups according to the degree of the jaundice (< or >2gr/dL), the bile duct's diameter(< or >1,2 cm) and the calculi's diameter (< or >1 cm). Later, the patients were directed to the trans-cystic clearance procedure (Group A, 141 patients) or to the rendezvous procedure (Group B, 39 patients). We prospectively analyzed each group based on sex, age, surgical time, conversion rate, success rate of proposed treatment, post-operative complications and hospital stay. Results: Trans-cystic clean-up for group A patients was successful in 134 patients (90%), 2 patients needed to undergo a laparo-endoscopy (failure) and 5 patients underwent laparotomy with a conversion rate of 3.2%. 35 patients (89%) of group B obtained VBP clean-up through rendezvous, 1 patient obtained clean-up through simple trans-cystic procedure (failure), while for 3 patients (9.1%) it was necessary to convert the surgery. Post-operative complications showed similar percentages for both groups. However, the surgical time turned out to be longer for the rendez-vous group (207.3±88.5 m vs 124±52.7 m) with a statistically significant difference(. p value = 0.0001). Conclusion: The one-stage procedure for the treatment of cholecysto-choledocolithiasis was possible in 90% of the cases utilizing a surgical technique selected according to the patient's case history.

Which differences do elderly patients present in single-stage treatment for cholecysto-choledocholithiasis?

Patients with symptomatic gallstones present common bile duct stones in approximately 10% of cases. It is possible to resolve both gallbladder and bile duct stones with a single procedure. The aim of this study is to determine the effectiveness of a single stage procedure for gallbladder and bile duct stones in the elderly patients and to expose the differences between the various techniques. From January 2008 to December 2013, we treated 1540 patients with gallbladder stones. In 152 cases, we also found bile duct stones. 150 of these were treated in a single stage procedure. We divided our patients into 2 groups: Group A was younger than 65 (104 patients); Group B was 65 or older (46 patients). We retrospectively compared sex, ASA score, conversion rate, success rate, post-operative complications, hospital stay, and treatment method. We had no intra-operative mortality. 1 patient in Group B, heart condition (ASA 4), died with multiple organ failure (MOF) 10 days after his operation. ASA score: 3.5 ± 0.5 in A vs 2 ± 0.9 in B (P 0.001), post-operative complications 6% in A vs 18.1% in B (P 0.0325) and hospital stay 4.1 ± 2.3 in A vs 9.5 ± 5.5 in B (P 0.0001) were significantly higher in Group B. No differences were found in term of success rate: 94% in A vs 90% in B (P 0.4944). The procedure used to obtain the clearance of the bile duct showed a different success rate across the two groups: for the patients under 65 years old, trans-cystic clearance (TC-CBDE) was successful in 90% of cases, and only 51% for those older than 65, where we had to recall 49% for laparo-endoscopic rendez-vous (RV-IOERC) (P 0.0014). In conclusion, single stage treatment is safe and effective also to elderly patients. The methods used in patients being younger than 65 years old is what appeared to be significantly different.

Laparoscopic CBD Exploration

Laparoscopic CBD exploration (LCBDE) is a cost effective, efficient and minimally invasive method of treating choledocholithiasis. Laparoscopic Surgery for common bile duct stones (CBDS) was first described in 1991, Petelin (Surg Endosc 17:1705-1715, 2003). The surgical technique has evolved since then and several studies have concluded that Laparoscopic common bile duct exploration(LCBDE) procedures are superior to sequential endolaparoscopic treatment in terms of both clinical and economical outcomes, Cuschieri et al. (Surg Endosc 13:952-957, 1999), Rhodes et al. (Lancet 351:159-161, 1998). We started doing LCBDE in 1998.Our experience with LCBDE from 1998 to 2004 has been published, Gupta and Bhartia (Indian J Surg 67:94-99, 2005). Here we present our series from January 2005 to March 2009. In a retrospective study from January 2005 to March 2009, we performed 3060 laparoscopic cholecystectomies, out of which 342 patients underwent intraoperative cholangiogram and 158 patients eventually had CBD exploration. 6 patients were converted to open due to presence of multiple stones and 2 patients were converted because of difficulty in defining Calots triangle; 42 patients underwent transcystic clearance, 106 patients had choledochotomy, 20 patients had primary closure of CBD whereas in 86 patients CBD was closed over T-tube; 2 patients had incomplete stone clearance and underwent postoperative ERCP. Choledochoduodenosotomy was done in 2 patients. Patients were followed regularly at six monthly intervals with a range of six months to three years of follow-up. There were no major complications like bile leak or pancreatitis. 8 patients had port-site minor infection which settled with conservative treatment. There were no cases of retained stones or intraabdominal infection. The mean length of hospital stay was 3days (range 2-8days). LCBDE remains an efficient, safe, cost-effective method of treating CBDS. Primary closure of choledochotomy in select patients is a viable & safe option with shorter operative time and length of stay. LCBDE can be performed successfully with minimal morbidity & mortality.

Intraoperative cholangiography facilitates simple transcystic clearance of ductal stones in units without expertise for laparoscopic bile duct surgery

In the absence of facilities and expertise for laparoscopic bile duct exploration (LBDE), most patients with suspected ductal calculi undergo preoperative endoscopic duct clearance. Intraoperative cholangiography (IOC) is not performed at the subsequent laparoscopic cholecystectomy. This study aimed to investigate the rate of successful duct clearance after simple transcystic manipulations. This prospective study investigated 1,408 patients over 13 years in a unit practicing single-session management of biliary calculi. For the great majority, IOC was attempted. Abnormalities were dealt with by flushing of the duct, glucagon injection, Dormia basket trawling, choledochoscopic transcystic exploration, or choledochotomy. Of 1,056 cholangiograms performed (75%), 287 were abnormal (27.2%). Surgical trainees, operating under supervision, successfully performed 24% of all cholangiograms. Of 396 patients admitted with biliary emergencies, 94.1% had abnormal cholangiograms. Of the 287 patients with abnormal IOCs, 9.4% required no intervention, 18% were clear after glucagon and flushing, and 13% were cleared using Dormia basket trawling under fluoroscopy. A total of 95 patients required formal LBDE, and 2 required postoperative endoscopic retrograde cholangiopancreatography (ERCP). No postoperative ERCP for retained stones was required after simple transcystic manipulation. Eight conversions occurred, one during a transcystic exploration. Follow-up evaluation continued for as long as 6 years in some cases. Two patients had recurrent stones after LBDE and a clear postoperative tube cholangiogram. In this series, 10% of the abnormal cholangiograms occurred in patients without preoperative risk factors for bile duct stones. Altogether, 88 IOCs (31%) were cleared after either simple flushing or trawling with a Dormia basket. Formal LBDE was not required for 40% of abnormal cholangiograms. Simple transcystic manipulations to clear the bile ducts justify the use of routine IOC in units without laparoscopic biliary expertise.