Management of Common Bile Duct Stones A Single-Center Experience (original) (raw)
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Management of Preoperatively Suspected Choledocholithiasis: A Decision Analysis
Journal of Gastrointestinal Surgery, 2008
Background The management of symptomatic or incidentally discovered common bile duct (CBD) stones is still controversial. Of patients undergoing elective cholecystectomy for symptomatic cholelithiasis, 5-15% will also harbor CBD stones, and those with symptoms suggestive of choledocholithiasis will have an even higher incidence. Options for treatment include preoperative endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy (ERCP/ES) followed by laparoscopic cholecystectomy, laparoscopic cholecystectomy with intraoperative cholangiogram (LC/IOC), followed by either laparoscopic common bile duct exploration (LCBDE) or placement of a common bile duct double-lumen catheter with postoperative management. The purpose of this analysis was to determine the optimal management of such patients. Methods A decision analysis was performed to analyze the management of patients with suspected common bile duct stones. The basic choice was between preoperative ERCP/ES followed by LC, LC/IOC followed by LCBDE, or common duct double-lumen catheter (Fitzgibbons tube) placement with either expectant management or postoperative ERCP/ES. Data on morbidity and mortality was obtained from the literature. Sensitivity analysis was done varying the incidence of positive CBD stones on IOC with associated morbidity and mortality. Results One-stage management of symptomatic CBD stones with LC/LCBDE is associated with less morbidity and mortality (7% and 0.19%) than two-stage management utilizing preoperative ERCP/ES (13.5% and 0.5%). Sensitivity analysis shows that there is an increase in morbidity and mortality for LC/LCBDE as the incidence of positive IOC increases but are still less than two-stage management even with a 100% positive IOC (9.4%, 0.5%). If a double-lumen catheter is to be used for positive IOC, the morbidity would be higher than two-stage management only if the positive IOC incidence is more than 65% but still with no mortality. Conclusion LCBDE has lower morbidity and mortality rates compared to preoperative ERCP/ES in the management of patients with suspected CBD stones even if the chance of CBD stones reaches 100%. Using a common duct double-lumen catheter may be considered if LCBDE is not feasible and the chance of CBD stone is less than 65%.
Preliminary experience with laparoscopic common bile duct exploration
BMC Surgery, 2017
Background: Herein we present our experience with laparoscopic common bile duct exploration (LCBDE) in managing common bile duct stones. Methods: Data of 129 consecutive patients who underwent laparoscopic cholecystectomy (LC) and LCBDE done at our institutes from April 2011 through June 2016 were prospectively recorded and retrospectively reviewed. Results: Since 2011, 3012 laparoscopic cholecystectomy were performed at our institutes, intraoperative cholangiogram (IOC) was done in 295 (9.8%) patients which detected choledocholithiasis in 129 (4.3%) of them. LCBDE was successful to clear the common bile duct (CBD) in 123/129 (95.4%). Six patients underwent postoperative endoscopic retrograde cholangiopancreatography (ERCP) because of incomplete CBD clearance (4 cases), symptomatic stenosed papilla (2 cases). LCBDE was performed in 103 patients via trans-cystic approach and choledochotomy one in 26 patients. In the choledochotomy group, seven patients had primary closure of the CBD, CBD was closed over T-tube in nine patients whereas the remaining 10 patients the CBD was closed over antegrade inserted stent. The median time of hospital stay was 4 (range; 1-15) days. No patients showed retained CBD stones with mean follow up was 9 ± 3.4 months. Conclusion: LCBDE is a safe and cost effective option for CBD stones in short-term outcome and can be performed provided proper laparoscopic expertise and facilities are available.
Outcomes of Laparoscopic Common Bile Duct Exploration by Chopstick Technique in Choledocholithiasis
JSLS, 2021
Background and Objectives:Laparoscopic cholecystectomy with common bile duct exploration (LC with LCBDE) remains the preferred technique for difficult common bile duct stone (CBDS) removal. The chopstick method uses commonly available instruments and may be cost-saving compared to other techniques. We studied the outcome of LCBDE using the chopstick technique to determine if it could be considered a first-choice method.Methods:Data from all patients that underwent LCBDE from January 1, 2012 to April 30, 2019 were retrospectively analyzed. A standard 4-port incision and CBDS permitted extraction with two laparoscopic instruments by chopstick technique via vertical choledochotomy. Demographic data, stone clearance rate, surgical outcomes, complications, and other associated factors were evaluated.Results:Thirty-two patients underwent LCBDE. The mean number of preoperative endoscopic retrograde cholangiopancreatography (ERCP) sessions was 2.4. In 65.5% of cases, the CBDS was completely removed by the chopstick technique, while 96.9% of stones were removed after using additional tools. The need for additional instruments was associated with increased age, increased numbers of stones, longer period from the latest ERCP session, and previous upper abdominal surgery. The conversion rate to open surgery was 28.1% and was significantly associated with a history of upper abdominal surgery.Conclusion:The chopstick technique is a good alternative and could be considered as a first-line technique in LCBDE to remove the CBDS in cases with 1 to 2 large suprapancreatic CBDS due to instrument availability, cost-effectiveness, and comparable surgical outcomes.
Laparoscopic Common Bile Duct Exploration: Minimally Invasive Management of Choledocholithiasis
Choledocholithiasis, the presence of gallstones within the common bile duct (CBD), is a common and potentially serious condition that demands prompt intervention. Laparoscopic common bile duct exploration (LCBDE) has gained recognition as an effective and minimally invasive approach to manage this condition, offering several advantages over traditional open procedures. This abstract provides an overview of the key aspects of LCBDE, encompassing patient selection, surgical techniques, outcomes, and recent advancements. Patient selection is a critical factor in achieving successful outcomes in LCBDE. The abstract discusses criteria for selecting appropriate candidates based on factors such as the size and location of CBD stones, the presence of associated gallbladder disease, and patient comorbidities. It underscores the importance of tailored treatment plans and comprehensive preoperative evaluation. The surgical techniques employed in LCBDE, including choledochotomy, stone extraction, and common bile duct exploration, are detailed to provide a comprehensive understanding of the procedure. The abstract highlights the benefits of laparoscopy, including smaller incisions, reduced postoperative pain, and quicker recovery times. Clinical outcomes associated with LCBDE are also discussed, focusing on successful stone clearance, reduced risk of complications, and shorter hospital stays. Potential complications and their management are addressed, emphasizing the significance of surgical expertise in minimizing adverse events. Furthermore, recent advancements in LCBDE, such as the use of intraoperative cholangiography, fluorescence-guided surgery, and the implementation of robotic-assisted systems, are highlighted. These innovations have contributed to enhancing the precision and success rates of the procedure while minimizing potential risks. In conclusion, laparoscopic common bile duct exploration has emerged as a highly effective and minimally invasive approach to manage choledocholithiasis, providing significant benefits for patients with CBD stones. This abstract provides an overview of the key aspects and recent advancements in this field, underlining its potential to improve patient outcomes and enhance the management of choledocholithiasis.
Journal of Laparoendoscopic & Advanced Surgical Techniques, 2020
Although laparoscopic cholecystectomy (LC) has become the gold standard for the management of gallstone disease, the application of laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis has been slower. The aim of this study is to determine the feasibility and effectiveness of LCBDE. A retrospective cohort study was conducted to compare LCBDE (n ؍ 82) with conventional common bile duct exploration (CCBDE) (n ؍ 75) and endoscopic sphincterotomy (EST) (n ؍ 80) in the management of choledocholithiasis. All our LCBDEs were performed through choledochotomy with T-tube placement. The mean operative time of the LCBDE group (124 ؎ 48 minutes) was not significantly longer then the CCBDE group (118 ؎ 35 minutes), while the postoperative hospitalization was shorter in both the LCBDE (8 ؎ 5 days) and EST (9 ؎ 4 days) groups than in the CCBDE (13 ؎ 6 days) group. In the LCBDE group, 14 patients (17.1%) required postoperative choledochoscopy to clear residual stones through the T-tube tract. The only mortality occurred in the CCBDE group. The morbidity rate was 3.7% (3/82) in the LCBDE group, including bile leakage in 1 case and bile peritonitis in 2 cases; 6.7% (5/75) in the CCBDE group, including atlectasis in 2 cases, sepsis in 1, and wound infection in 2. There were 2 cases of postoperative pancreatitis (2.5%; 2/80) in the EST group. The difference in the average number of sessions needed for complete clearance of choledocholithiasis in each group was statistically significant (EST, 1.46 ؎ 0.67; LCBDE, 1.23 ؎ 0.42; and CCBDE, 1.09 ؎ 0.28; P Ͻ 0.0001). Our results suggested that EST and LCBDE tended to require more therapeutic sessions then CCBDE, although these sessions were less invasive. The benefits of LCBDE include minimal invasiveness, concurrent treatment of gallbladder stone and CBD stones in a single session, and a shorter postoperative hospital stay. However a longer learning curve is needed. Selection of the most suitable therapeutic option for individual patients by an experienced surgeon gives the most benefits to patients.
International Surgery Journal, 2019
Background: Endoscopic retrograde cholangiopancreatography (ERCP) with consequent laparoscopic cholecystectomy (LC) has been the favored approach for the treatment of choledocholithiasis for a long time; however recently, laparoscopic common bile duct exploration (LCBDE) has been offered to patients with suspected choledocholithiasis. Objective and aim of this work was to compare the efficacy, safety, and the surgical outcomes of LCBDE with ERCP followed by LC and determine the most appropriate approach for patients with choledocholithiasis.Methods: A prospective clinical study was carried out from March 2017 to September 2018. It included 50 patients with cholecysto-choledocholithiasis who were divided into two groups: group A (25 patients) included patients who underwent transcystic LCBDE and stone extraction with LC in one stage, and group B (25 patients) included patients who underwent ERCP followed by LC in two stages. The common bile duct (CBD) stone clearance rate, postoperat...
American Journal of Surgery, 2017
A best evidence topic in surgery was written according to a structured protocol. The question addressed was: in patients with symptomatic gallstones and concomitant common bile duct (CBD) stones, is a single-stage surgical strategy (laparoscopic cholecystectomy (LC) with common bile duct exploration) preferable, or a two-stage procedure involving LC with pre or post-operative endoscopic retrograde cholangiography (ERCP)? Two hundred and six papers were found using the reported search, of which four presented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group, study type, relevant outcomes and results of these papers are tabulated. A recent large meta-analysis concluded no significant difference in the clinical effectiveness or complication rate of either strategy. Three recent smaller studies concurred with this conclusion; however each noted improved cost-effectiveness of the single-stage approach advocating its use as the superior strategy when local resources and expertise are available. We conclude that for patients with symptomatic gallstones and concomitant choledocholithiasis, a single-stage surgical procedure is equivalent to two-stage LC and ERCP in terms of clinical outcomes, is associated with a shorter overall hospital stay and may be more cost-effective. On this basis a singlestage procedure is recommended for management of symptomatic gallstones and choledocholithiasis where local resources and expertise permit.
Managing choledocholithiasis in the laparoscopic era
American Journal of Surgery, 1995
sAc1cGt7our~: Management options for common bile duct stones have expanded in the era of iaparoscopk choiecystectomy (LC), and seiecting the most appropriate method for each patient can be probtematic due to the difficulty of predicting accurately which patients have choiedochdithiaris (CDL). in order to improve seiection of appropriate treatment for CDL, treatment options were analyzed for outcome retrospectively during a 25-month period beginning June 1,1882.