BV Martian, BI Diaconescu, M Beuran
Emergency Clinical Hospital Bucharest "Floreasca"
Summary: Despite many advances in the last decades the optimal treatment for concomitant gallstones and common bile duct (CBD) stones is still controversial. While for the asymptomatic gallbladder stones the need for surgery is still under debate, there is large consensus regarding the indication to remove the CBD stones, which appear to be associated in 3-10% of patients (1).
Before the laparoscopic era the standard treatment for CBD stones was open cholecystectomy and CBD exploration. For the patients unfit for surgery, or with severe complications such as acute cholangitis, jaundice and pancreatitis, ERCP with endoscopic sphincterotomy (ES) and stone extraction was a valuable, seldom stand alone, life saving, alternative. With the advent of laparoscopic cholecystectomy (LC) in 1987-1988, new techniques added to the armamentarium of CBD stones treatment. Reddick & Olsen (2,3) sustained the ERCP with endoscopic sphincterotomy (ES) and stone extraction as early as 1990; Petelin (4), almost simultaneously, introduced the laparoscopic CBD exploration (LCBDE). The current standards of practice recognise 3 options: the combined laparo-endoscopic, the totally laparoscopic and the open approach. The present paper is aiming to discuss these options with a focus on LCBE.
The choice between the 3 options is depending on many factors, given the final objective to obtain CBD clearance in the safest way, with minimal patient aggression and in the most cost-effective manner.
The first aspect to discuss is the stone detection moment: preoperative, intra or postoperative. The preoperative CBD stones diagnosis is problematic. The most predictive sign appears to be acute cholangitis, with up to 100% CBD stones present (5). The clinical signs suggestive for CBD stones such as cholecystitis, biliary colic, acute pancreatitis and jaundice proved to be associated with stones in 7%, 16%, 20% and 45% of cases respectively (5). The case is similar for the lab tests, with up to 50% false positive/negative results. The standard transabdominal US, while very sensible in showing gallbladder stones has only 50-80% specificity in detecting CBD stones and, in addition, is very operator dependent. From the opposite perspective it has been demonstrated on 1000 consecutive LC with intraoperative cholangiography (IOC) and unsuspected CBD stones the presence of calculi in 14.2% of cases (5). Thus, confirmation tests are necessary for preoperative detection.
ERCP is highly sensitive (90-95%) in detecting CBD stones and extracting them (over 90%) when ES is associated. However, it is an invasive procedure and has been shown to have significant post procedural morbidity - bleeding, perforation, acute pancreatitis - in 16% of cases, even related mortality in 1% (6). Additionally, even if strict criteria based on high suspicion index for CBD stones are used, only 10-60% of patients will actually have stones at the time of ES (7,8). As a result, a number of unnecessary ERCP-ES procedures are being performed, with their own morbi-mortality. Currently, ERCP is no longer accepted for CBD stones detection; it is a valuable instrument for preoperative use in patients with confirmed stones, for treatment purposes only (9). Some authors have advocated ES either concomitant, or post LC (stones detected by IOC or operative US), thus avoiding the unnecessary ERCP-ES. There are clear advantages, yet post ERCP morbidity & mortality remain the same (10).
EUS is a more recent valuable diagnostic test. Some centres which perform routinely preoperative EUS report 98% sensitivity and 99% specificity (11). The problem is, more than for conventional US, the operator dependancy. Never the less, in trained centres, it an excellent alternative for preoperative stone detection.
Magnetic resonance cholangiopancreatography (MRCP) is another alternate diagnostic test with 95-100% accuracy in detecting CBD stones (12). It is non invasive, less operator dependent and considered the current diagnostic standard for patients with medium to high suspicion index for choledocolithiasis (9). The problems with MRCP are availability and high cost which limit its usage. Short sequence MRCP might limit cost without impeding on accuracy (12).
Helical computed tomography (HCT) is a newer test, with comparable value to MRCP (13). The disadvantage is linked with contrast injection.
Diffrent modalities for succesfully treating common bile duct stones are accepted. The appropiate therapy depends on the patient’ s condition and more important the equipment, local expertise in laparoscopy, endoscopy and interventional radiology. Practice there are recognised three options: the combined laparo-endoscopic with endoscopy prior to surgery, the totally laparoscopic and the open approach. Noble designed one trial to compare single stage (LC + LCBDE) aproach with two stage (ERCP + LC) aproach in higher risk patient (over 50 years with BMI higher than 40, over 60 years with comorbidity or those over 70 years). (14) Patients with severe pancreatitis and cholangitis or wich require emergency ERCP were excluded.
Endoscopic retrograde colangiography plays an important role in the early treatment of common bile duct stones for patients with jaundice, cholangitis or severe pancreatitis. Also for patients with elderly who may not tolerate an operation, performing ERCP and leaving the gallbladder in situ is an alternative but with a lot of risks. However the routine ERCP for suspected choledocholithiasis is not accepted. There are some studies who demonstate that up to 61% of patients with suspected common duct stones undergo an unnecessary ERCP andd wich maybe is associated with morbities.(15)
Much of the morbidity linked with ERC/ES is associated with the sphincterotomy. Endoscopic papillary dilation has been suggested as an alternative; however, a recent multicenter, controlled randomized study demonstrated that endoscopic balloon dilatation resulted in a higher rate of pancreatitis compared with sphincterotomy and recommended that it should be avoided in routine practice. (16)
Laparoscopic CBD explorationcan take place via the cystic duct (transcystic technique) or by directly incising and opening the CBD with stone retrieval (laparoscopic choledochotomy). Small stones can often be ﬂushed through the ampulla into the duodenum. Intravenous glucagon may be used to relax the sphincter of Oddi, followed by ﬂushing of 100–200 ml of saline. When these methods fail, a helical stone basket can be passed over a guide wire through the cystic duct and into the CBD to extract stones under ﬂuoroscopic guidance. If attempts at transcystic basket extraction fail, a choledochoscope (<10 Fr) should be tried next to remove the stones under direct vision. If the CBD stone is larger than the lumen of the cystic duct, the cystic duct should ﬁrst be balloon-dilated to a maximum of 8 mm diameter, but never larger than the internal diameter of the CBD.(17)
If the transcystic approach fails, we recommend laparoscopic longitudinal choledochotomy. Indications for choledochotomy are multiple or large stones with small distal CBP or those positioned within the proximal bile ducts in patients with a CBD diameter larger than 8–10 mm. Choledochoraphy is accomplished with ﬁne absorbable sutures by using intracorporeal suturing techniques and if a T-tube is used, it is exteriorized through the lateral port site. Others have shown decreased complications with primary closure compared with T-tube use.
The patient is generally discharged 2–4 days postoperatively. If a T-tube is used, a ﬁnal cholangiogram is performed 2-3 weaks postoperatively with removal of the tube if no abnormalities are found. Others have shown decreased complications with primary closure compared with T-tube use.(18)
Prospective randomized trial comparing two-stages with single – stage management demonstrate equivalent succes rate for laparoscopic common bile duct exploration versus ERCP followed by laparoscopic cholecystectomy with reduced hospital stay for laparoscopy.(19)
Open CBD exploration should be considered the good technique adapted to local situation, not a ‘‘failure’’, if laparoscopic CBDE and/or postoperative ERC are unsuccessful. The most common reason to convert to open CBDE is an impacted stone at the ampulla of Vater, and these cases require a transduodenal exploration. Open CBDE should also be considered as the initial procedure of choice if patients present with dilated CBD or multiple common bile duct stones. This entails either performing a choledochoenterostomy.
In Emergency Clinical Hospital Floreasca magnetic resonance cholangiopancreatography (MRCP) and, when it is not available, computed tomography have been used to diagnose choledocholithiasis. Also intraoperative cholangiography is used in selective cases. Diagnostic ERCP is abandoned. Regarding our experience the standard is SE + CL.
The experience with LCBDE is limited to a single surgical team and it is occasionally because of financial difficulties. Between 2001 and 2008, 108 patients were operated in laparoscopic aproach. The exclusion criteria were papillary impaction, acute pancreatitis, acute cholangitis or other severe comorbidities. The diagnosis was confirmed by MRCP in 69 patients, 8 patients by ultrasound and in 32 cases by cholangiography. In 40 cases we used choledochoscope and we confirmed the choledocholithiasis. The first choice for us is remove the stones by transcystic approach because it is technically simple, is effective in more than 85% of cases and does not affect CBP. Laparoscopic coledocotomy was performed for 63 patients getting clearance in 62 cases.
Open surgery remains an option for failure of minimally invasive methods, intrahepatic lithiasis, complex CBP lithiasis or in particular cases of acute cholangitis.
Choledocolithiasis remains a complicated and challenging disease with a treatments which depends on operator expertise and available resources. Single-stage is equivalent in terms of results about postoperative morbidity and mortality with two-stages therapy but reduces the number of procedures per patients.
1. Collins C, Maguire D, Ireland A, Fitzgerald E, O’Sullivan GC. A prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of choledocholithiasis revisited. Ann Surg 2004; 239: 28-33
2. Reddick EJ, Olsen DO, Alexander W, et al. (1990) Laparoscopic laser cholecystectomy and choledocholithiasis. Surg Endosc (1988) 4:133-134
3. Cuschieri A, Dubois F, Mouiel J, et al. (1991) The European experience with laparoscopic cholecystectomy. Am J Surg 161: 385-387
4. Petelin JB (1991) Laparoscopic approach to common duct pathology. Surg Laparosc Endosc 2: 33-41.
5. Tranter SE, Thompson MH. Spontaneous passage of bile duct stones: Frequency of occurrence and relation to clinical presentation. Ann R Coll Surg Engl 2003;85:174–177.
6. Wang p, Li ZS, liu F et al. Risk factors for ERCP related complications: a prospective multicenter study. Am J Gastroenterol 2009; 104: 31-40
7. Bergamaschi R, Tuech JJ, Braconier L, Walsøe HK, Mårvik R, Boyet J, Arnaud JP. Selective endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy for gallstones. Am J Surg 1999; 178: 46-49
8. Coppola R, Riccioni ME, Ciletti S, Cosentino L, Ripetti V, Magistrelli P, Picciocchi A. Selective use of endoscopic retrograde cholangiopancreatography to facilitate laparoscopic cholecystectomy without cholangiography. A review of 1139 consecutive cases. Surg Endosc 2001; 15: 1213-1216
9. EAM Neugebauer, S Sauerland, A Fingerhut, B Millat, G Buess. EAES Guidelines for Endoscopic Surgery, Springer 2006, p 330
10. Vandervoort J, Soetikno RM, Tham TC, Wong RC, Ferrari AP, Montes H, Roston AD, Slivka A, Lichtenstein DR, Ruymann FW, Van Dam J, Hughes M, Carr-Locke DL. Risk factors for complications after performance of ERCP. Gastrointest Endosc 2002; 56: 652-656
11. Buscarini E, Tansini P, Vallisa D, Zambelli A, Buscarini L. EUS for suspected choledocholithiasis: do benefits outweigh costs? A prospective, controlled study. Gastrointest Endosc 2003;57:510–518.
12. Shamiyeh A, Linder E, Danis J, et al. Short-versus long sequence MRI cholangiography for the preoperative imaging of the common bile duct in patients with cholecystolithiasis. Surg Endosc 2005;19:1130–1134.
13. Kondo S, Isayama H, Akahane M, et al. Detection of common bile duct stones: comparison between endoscopic ultrasonography, magnetic resonance cholangiography, and helical-computed-tomographic cholangiography. Eur J Radiol 2005;54:271–275.
14. Noble H, Tranter S, Chesworth T, Norton S, Thompson M. A randomized, clinical trial to compare endoscopic sphinc- terotomy and subsequent laparoscopic cholecystectomy with primary laparoscopic bile duct exploration during cholecystectomy in higher risk patients with choledocholi- thiasis. J Laparoendosc Adv Surg Tech A 2009; 19: 713-720
15. Nataly Y. Merrie AE, Stewart ID Selective use of preoperative endoscopic retrograde cholangiopancreatography in the era of laparoscopic cholecistectomy ANZ J Surg 2002, 72:186-189
16. Tai CK, Tang CN, Ha JP, Chau CH, Siu WT, Li MK. Lap- aroscopic exploration of common bile duct in difﬁcult chol- edocholithiasis. Surg Endosc 2004;18:910–914.
17. Hunter JG, Soper NJ. Laparoscopic management of common bile duct stones. Surg Clin North Am 1992;72:1077–1097.
18. Petelin JB. Laparoscopic common bile duct exploration. Surg Endosc 2003;17:1705–1715.
19. Cuscheri A, Lezoche E, Morino M, et all EAES multicenter prospective randomized trial comparing two-stages vs single stage management of patients with gallstone disease and ductal calculi. Surg. Endosc 1999, 13: 952-957
20. Management of Common Bile Duct Stones, Eric S. Hungness, M.D., Nathaniel J. Soper, M.D. Journal of Gastrointestinal surgery Vol10, 2006, nr 4, 612- 619