- Email: [email protected]
Laparoscopic management after failed endoscopic stone removal in nondilated common bile duct
Accepted Manuscript Laparoscopic management after failed endoscopic stone removal in nondilated common bile duct Zang Jinfeng, M.D., Yuan Yin, M.D., Zhang Chi, M.D., Gao Junye, M.D. PII:
S1743-9191(16)00255-7
DOI:
10.1016/j.ijsu.2016.03.037
Reference:
IJSU 2681
To appear in:
International Journal of Surgery
Received Date: 12 December 2015 Revised Date:
13 March 2016
Accepted Date: 17 March 2016
Please cite this article as: Jinfeng Z, Yin Y, Chi Z, Junye G, Laparoscopic management after failed endoscopic stone removal in nondilated common bile duct, International Journal of Surgery (2016), doi: 10.1016/j.ijsu.2016.03.037. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Laparoscopic management after failed endoscopic stone removal in nondilated
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common bile duct
Running title: Laparoscopic management after failed endoscopic procedure
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Zang Jinfeng, Yuan Yin, Zhang Chi, Gao Junye
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Zang Jinfeng, M.D., Department of Hepatobiliary Surgery, Taizhou People’s Hospital, the Fifth Affiliated Hospital of Medical School of Nantong University, Taizhou 225300, Jiangsu Province, China. [email protected]
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Yuan Yin, M.D., Department of Hepatobiliary Surgery, Taizhou People’s Hospital, the Fifth Affiliated Hospital of Medical School of Nantong University, Taizhou
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225300, Jiangsu Province, China. [email protected]
Zhang Chi, M.D., Department of Hepatobiliary Surgery, Taizhou People’s Hospital,
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the Fifth Affiliated Hospital of Medical School of Nantong University, Taizhou 225300, Jiangsu Province, China. [email protected]
Gao Junye, M.D., Department of Hepatobiliary Surgery, Taizhou People’s Hospital, the Fifth Affiliated Hospital of Medical School of Nantong University Taizhou 225300, Jiangsu Province, China. [email protected]
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Corresponding author: Zang Jinfeng, Department of Hepatobiliary Surgery, Taizhou
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People’s Hospital, No. 210, Yingchun Road, Taizhou 225300, Jiangsu Province,
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China. Tel: +86-13775687933, Fax: +86-523-86225199. E-mail: [email protected]
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Laparoscopic management after failed endoscopic stone removal in
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nondilated common bile duct
ABSTRACT
Introduction: When common bile duct (CBD) stone removal by endoscopic procedure
fails, CBD exploration is an alternative procedure. However, nondilated CBD is a
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contraindication to choledochotomy. The purpose of this study was to investigate the
results of laparoscopic CBD exploration (LCBDE) following unsuccessful endoscopic
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stone removal in nondilated CBD.
Methods: From January 2011 to June 2015, we retrospectively analyzed 165 LCBDEs. Group 1 was defined as patients with nondilated CBD who underwent LCBDE after failed endoscopic stone removal. Group 2 included patients with dilated CBD who received primary LCBDE. Outcomes of LCBDE were compared between the two groups.
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Results: There were 23 patients in Group 1 and 142 in Group 2. No significant differences were observed in demographics other than CBD diameter. There was no significant difference in operating time, postoperative hospital stay, open conversion
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rate, overall postoperative complication rate, retained stone rate, and recurrence rate between the two groups.
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Conclusion: LCBDE in experienced hands is a safe and feasible option after failure of endoscopic stone removal in nondilated CBD. However, larger numbers of cases and longer follow-up are required to validate LCBDE in nondilated CBD.
Keywords: Choledocholithiasis; Laparoscopic surgery; Endoscopic surgery
1. Introduction Five to 15% of patients with gallstones have concomitant common bile duct (CBD) stones [1]. Endoscopic retrograde cholangiopancreatography (ERCP) and
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endoscopic sphincterotomy have dramatically changed the management of CBD stones. Endoscopic stone removal is quick, often painless, and is usually successful. However, there are reports of adverse effects of endoscopic sphincterotomy. These
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include pancreatitis, duodenal perforation and bleeding [2-4]. Laparoscopic CBD exploration (LCBDE) was another revolution in the minimally invasive era that came
with the development of laparoscopic cholecystectomy (LC). LCBDE can manage
gallstones and CBD stones during the same session safely and effectively with the
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advantage of minimal access. However, LCBDE is difficult, risky, and time consuming, especially in patients with nondilated CBD. Both LCBDE and endoscopic
stone removal have been used to treat CBD stones for many years. Some randomized
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clinical studies have shown that they have similar rates of stone clearance, morbidity, and mortality, while LCBDE is associated with a shorter hospital stay and is more cost-effective compared with ERCP [5-7]. In fact, LCBDE and endoscopic procedure should be considered complementary and their roles defined appropriately according to different indications.
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Despite technical innovations, structured training programs and improved endoscopic imaging, failed biliary cannulation during ERCP occurs in 5–20% of all cases [4]. When endoscopic stone removal fails, LCBDE is an acceptable choice [8,9]. However, it remains unclear whether laparoscopic management is an optimal
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alternative to patients with nondilated CBD after an unsuccessful endoscopic procedure. The purpose of this study was to present our experience of LCBDE as a
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salvage procedure for failed endoscopic stone removal in nondilated CBD.
2. Materials and methods 2.1. Patients
From January 2011 to June 2015, 165 patients with gallstones and concomitant CBD stones who underwent LC and LCBDE during the same session at Taizhou People’s Hospital (Taizhou, Jiangsu Province, China) were included in this retrospective study. Medical records, endoscopic and operative reports were retrieved from a review of inpatient files. Patients were further classified into two groups. In Group 1, 23 patients
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with nondilated CBD underwent LC and LCBDE after failed endoscopic stone removal. In Group 2, 142 patients with dilated CBD underwent LC and LCBDE. Nondilated CBD was defined as diameter <8 mm. The study was approved by the
each patient. 2.2. Operative procedure
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ethics committee of our hospital, and informed written consent was obtained from
All patients underwent preoperative blood examination, electrocardiography, chest and
abdominal
ultrasonography.
Magnetic
resonance
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X-ray,
cholangiopancreatography was performed routinely to detect CBD stones in our center. Consultant surgeons performed LCBDE. Our standard operative technique
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included abdominal access for laparoscopic exploration using two 5-mm and two 10-mm trocars. All patients underwent supraduodenal longitudinal choledochotomy and extraction of CBD stones by intraoperative choledochoscopy. We routinely performed T-tube (12–20 Fr depending on the diameter of the bile duct) drainage and cholecystectomy after CBD clearance. Choledochorraphy was carried out using
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interrupted sutures. A subhepatic drain was inserted at the end of the procedure, and removed within three postoperative days, as long as the drainage fluid was <20 ml/day and free of bile. T-tube drainage was removed after cholangiography to exclude retained CBD stones at 6 weeks after surgery. In the case of retained CBD
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stones indicated by cholangiography, we performed choledochoscopic extraction of stones via the sinus tract of the T-tube. After discharge, patients were followed up
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every 3 months during the first year and annually thereafter (with clinical evaluation, liver function tests and ultrosonography). According to the findings, we used additional imaging studies to rule out biliary stricture and recurrent CBD stones. 2.3. Statistical analysis The statistical data were analyzed using the t test, Pearson’s χ2 test or Fisher’s exact test. Data were analyzed using SPSS for Windows version 17.0 (SPSS Inc., Chicago, IL, USA). p < 0.05 was considered statistically significant.
3. Results
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3.1. Patient characteristics In Group 1, 19 patients failed ERCP because of unsuccessful biliary cannulation. Four patients underwent LCBDE because of retained CBD stones after ERCP. We
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performed emergency LCBDE in three patients with acute cholangitis. In Group 2, 21 patients required emergency LCBDE. No significant differences were identified with respect to age, gender and other medical conditions, except for CBD diameter. The
characteristics of the two treatment groups, including main preoperative biochemical
3.2. Outcome of laparoscopic procedure
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data, are shown in Table 1.
There was no mortality in the treatment groups. One patient (4.35%) in Group 1 was
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converted to open surgery and three (2.11%) in Group 2 because of marked adhesions, leading to difficult anatomy and dissection. Duration of surgery was 122.6 min in Group 1 and 117.5 min in Group 2 (p = 0.11). There was no significant difference in postoperative hospital stay between the groups (p = 0.48).
There was no difference in the overall postoperative complication rate between
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the groups (8.70% for Group 1 vs 2.82% for Group 2). One patient in Group 1 and three in Group 2 presented with bile leakage in the postoperative 3 days. All were treated conservatively. The subhepatic drain was sufficient, and no extra drainage procedures were required, and the drain was removed within 5 days after surgery.
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Intra-abdominal bleeding after surgery occurred in one patient in Group 1, which was treated conservatively. One patient in Group 2 was complicated with postoperative
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intra-abdominal infection, which was managed with intravenous antibiotics and percutaneous drainage. No patients developed biliary stricture in either group. No patients in Group 1 and two in Group 2 had retained CBD stones (diagnosed
within 6 months after operation). One case of retained stones was detected by cholangiography and successfully treated by postoperative choledochoscopy. One patient with retained stones after T-tube removal underwent ERCP, with successful stone extraction. We found recurrent CBD stones in one patient in Group 1 and two patients in Group 2. All of these recurrent CBD stones were successfully removed by ERCP. The outcomes of LCBDE are shown in Table 2.
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4. Discussion Treatment options for concomitant gallstones and CBD stones include
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single-stage cholecystectomy and CBDE or a two-stage procedure via ERCP before or after cholecystectomy. The best approach remains controversial. As no consensus has been achieved, management of CBD stones seems to be decided more by
availability of instrumentation, personnel and skills than cost-effectiveness. As
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therapeutic ERCP enters its fourth decade, short- and longer-term results are now available and some disadvantage is becoming apparent. Although the short-term complication rate of ERCP has decreased with greater experience, pancreatitis
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continues to be a problem with an incidence rate of 5% [2,3,10]. Long-term follow-up has demonstrated the late biliary complications of endoscopic sphincterotomy, including duodenobiliary reflux and high rate of recurrent CBD stones [11]. Permanent destruction of biliary sphincter after sphincterotomy results in duodenobiliary reflux and a high rate of bacterobilia [12]. Confirmed duodenobiliary
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reflux and bacterial contamination of the bile ducts are responsible for the continuing duct stone formation. Therefore, it seems that there is a good case for preserving the biliary sphincter in patients with CBD stones. Although many studies have shown that LCBDE is more cost-effective and
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beneficial for preservation of papillary function than ERCP is, conventional T-tube placement in LCBDE as an open procedure increases postoperative complications.
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The benefits of T-tube placement include decompression of the bile duct to minimize leakage, prevention of postoperative strictures, and provision of access for detection and extraction of retained stones. In our center, LCBDE with T-tube has been performed to manage CBD stones since 2005 by a single surgical team. The low rate of CBD stone recurrence and absence of biliary stricture demonstrate that this procedure can be performed with good long-term results in the treatment of CBD stones. In CBDs with normal diameter, we would rather place the T-tube conventionally as a stent and pressure-relief tool. The absence of biliary stricture and severe bile leakage in our study indicated clearly the necessity for T-Tube placement
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in such unorthodox conditions of the bile duct. However, patient discomfort caused by T-tube drainage remains the Achilles heel of this technique. Therefore, many surgeons try to perform LCBDE with primary closure, which shows a significant
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reduction in hospital stay and duration of operation with similar complication rates between LCBDE and T-tube drainage [13-15]. T-tube-free LCBDE could result in laparoscopic procedures becoming the optimal treatment for CBD stones.
Despite advances in equipment and expertise, selective cannulation of the CBD in
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ERCP remains occasionally challenging, even for an experienced endoscopist. Biliary cannulation cannot be achieved because of special anatomical features, inflammatory
processes, and periampullary diverticula. Some authors assert that low-risk patients
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undergoing failed ERCP without other complications could be successfully and safely treated by repeated ERCP if referred to an experienced high-volume endoscopy center [16]. However, repeated ERCP is bound to increase patient burden and the incidence of ERCP-related complications. As a referral hospital, our center has to admit patients with failed ERCP. In this study, unsuccessful cannulation and migration of stones
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from the CBD to intrahepatic bile duct during ERCP were the main reasons for changing surgical procedure. After failed endoscopic stone removal, two therapeutic options remain: percutaneous techniques or surgical duct exploration. In dilated bile ducts, percutaneous removal of CBD stones is a nonsurgical and
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useful option [17,18]. Kint et al. reported a series of 110 consecutive patients with percutaneous transhepatic removal of CBD stones, including 60 who underwent failed
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ERCP. Complete stone clearance was accomplished in 104 patients (94.5%) after a median of 1.6 procedures, while first-time success was achieved only in 60 patients (54.5%). Even now, percutaneous methods are still used and considered to be reliable in our center when ERCP fails in dilated bile ducts. CBD diameter <8 mm is regarded as a contraindication to LCBDE, therefore, open CBD exploration becomes the last resort when endoscopic stone removal is unsuccessful in nondilated CBD. After our mastery of LCBDE, we attempted to manage failed ERCP in nondilated CBD using a laparoscopic procedure. Performing LCBDE in nondilated CBD requires particular skills and specialized
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equipment. First, CBD stones and the biliary tree should be delineated precisely with the
help
of
reliable
imaging
techniques,
including
magnetic
resonance
cholangiopancreatography and intraoperative cholangiography. Information from
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imaging examination contributes to deciding upon the length of CBD incision and selecting the method of stone removal, which is beneficial for protecting the tender nondilated CBD. Second, care is required when choosing a T-tube of appropriate size
and performing suturing with suitable stitches. Our experience shows that the
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diameter of the T-tube is smaller and the stitching is sparser when closure is conducted in the nondilated CBD. Lastly, LCBDE involves the management of instruments and technology that are not usually handled by the surgeons themselves.
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These consist of balloon dilators, choledochoscopes, and different baskets, which demand special cooperation between surgical team members. By virtue of intraoperative choledochoscopy, stone extraction can be performed under direct vision, and the incidence of retained stones in our study was low [19]. Therefore, constructing a sophisticated laparoscopic team becomes particularly important as
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LCBDE is undertaken in the context of complex choledocholithiasis, including large stones, impacted stones, and slender CBDs. Although we prefer routine use of the transcholedochal route in LCBDE, we realize that there are some other methods that can be applied in nondilated CBD. The
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transcystic LCBDE has been championed as the best treatment for CBD stones because it avoids choledochotomy and offers the same postoperative course as LC
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does [20]. However, due to the restrictions of the transcystic route and the disappointing success rates of this method (<60%), indications for an attempt at transcystic LCBDE are limited to fewer stones, stones located distal to the cyst–CBD junction, and smaller stones [21]. Some surgeons have performed LCBDE via the confluence of the cystic duct and bile duct as it may be technically easier to remove stones and less likely to result in strictures even in nondilated CBD [22,23]. Kim et al. defined this technique as LCBDE using a V-shaped choledochotomy and believed that it may offer an option for managing patients who are not able to undergo surgical treatment due to a narrow cystic duct or CBD. In addition, the laparo-endoscopic
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rendezvous procedure appears to be a valuable method when biliary cannulation in ERCP fails [24-26]. This procedure is associated with a higher success rate, shorter hospital stay, and fewer complications with sequential ERCP and LC. The size of the
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CBD would not affect the results of treatment if some organizational problems between endoscopists, surgeons and operating room personnel were dealt with tactfully.
The present study had some limitations. It was a retrospective observational study
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and open to selection bias. This was minimized by analyzing a consecutive series of
patients who had undergone LCBDE by a single experienced laparoscopic team. The
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small sample size weakened the validity of the results.
5. Conclusion
This study demonstrates that the efficacy and safety of LCBDE are similar between the two groups. LCBDE in experienced hands is a safe and feasible option after failure of endoscopic stone removal in nondilated CBD. Although the
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preliminary results are encouraging, larger numbers of cases and longer follow-up are needed to validate LCBDE in nondilated CBD.
Conflicts of interest
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References
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The authors have no conflicts of interest to declare.
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4 Williams EJ, Taylor S, Fairclough P, Hamlyn A, Logan RF, Martin D, et al., Are we meeting the standards set for endoscopy? Results of a large-scale prospective survey of endoscopic retrograde cholangio-pancreatograph practice, Gut. 56 (2007) 821-829.
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5 Rogers SJ, Cello JP, Horn JK, Siperstein AE, Schecter WP, Campbell AR, et al., Prospective randomized trial of LC+LCBDE vs ERCP/S+LC for common bile duct stone disease, Arch Surg. 145 (2010) 28-33.
6 Koc B, Karahan S, Adas G, Tutal F, Guven H, Ozsoy A, Comparison of common
bile
duct
exploration
and
endoscopic
retrograde
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laparoscopic
cholangiopancreatography plus laparoscopic cholecystectomy for choledocholithiasis: a prospective randomized study, Am J Surg. 206 (2013) 457-463.
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7 Bansal VK, Misra MC, Rajan K, Kilambi R, Kumar S, Krishna A, et al., Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with concomitant gallbladder stones and common bile duct stones: a randomized controlled trial, Surg Endosc. 28 (2014) 875-885.
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8 Paik KY, Kim EK, Laparoscopic common bile duct exploration after unsuccessful endoscopic stone removal, J Laparoendosc Adv Surg Tech A. 23(2013) 137-140. 9 Zhou Y, Wu XD, Fan RG, Zhou GJ, Mu XM, Zha WZ, et al., Laparoscopic common bile duct exploration and primary closure of choledochotomy after failed
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Incidence rates of post-ERCP complications: a systematic survey of prospective studies, Am J Gastroenterol. 102 (2007) 1781-1788. 11 Ding G, Cai W, Qin M, Single-stage vs. two-stage management for concomitant gallstones and common bile duct stones: a prospective randomized trial with long-term follow-up, J Gastrointest Surg. 18 (2014) 947-951. 12 Bergman JJ, van Berkel AM, Groen AK, Schoeman MN, Offerhaus J, Tytgat GN, et al., Biliary manometry, bacterial characteristics, bile composition, and histologic changes fifteen to seventeen years after endoscopic sphincterotomy, Gastrointest Endosc. 45 (1997) 400-405.
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13 Cai H, Sun D, Sun Y, Bai J, Zhao H, Miao Y, Primary closure following laparoscopic
common
bile
duct exploration
combined
with
intraoperative
cholangiography and choledochoscopy, World J Surg. 36 (2012) 164-170.
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14 Zhang HW, Chen YJ, Wu CH, Li WD, Laparoscopic common bile duct exploration with primary closure for management of choledocholithiasis: a retrospective analysis and comparison with conventional T-tube drainage, Am Surg. 80 (2014)178-181.
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15 Yi HJ, Hong G, Min SK, Lee HK, Long-term Outcome of Primary Closure After Laparoscopic Common Bile Duct Exploration Combined With Choledochoscopy, Surg Laparosc Endosc Percutan Tech. 25 (2015) 250-253.
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16 Swan MP, Bourke MJ, Williams SJ, Alexander S, Moss A, Hope R, et al., Failed biliary cannulation: Clinical and technical outcomes after tertiary referral endoscopic retrograde cholangiopancreatography, World J Gastroenterol. 17 (2011) 4993-4998. 17 Healy K, Chamsuddin A, Spivey J, Martin L, Nieh P, Ogan K, Percutaneous endoscopic holmium laser lithotripsy for management of complicated biliary calculi,
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JSLS. 13 (2009) 184-189.
18 Kint JF, van den Bergh JE, van Gelder RE, Rauws EA, Gouma DJ, van Delden OM, et al., Percutaneous treatment of common bile duct stones: results and complications in 110 consecutive patients, Dig Surg. 32 (2015) 9-15.
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19 Topal B, Aerts R, Penninckx F, Laparoscopic common bile duct stone clearance with flexible choledochoscopy, Surg Endosc. 21 (2007) 2317-2321.
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20 Hanif F, Ahmed Z, Samie MA, Nassar AH, Laparoscopic transcystic bile duct exploration: The treatment of first choice for common bile duct stones, Surg Endosc. 24 (2010)1552-1556.
21 Gigot JF, Navez B, Etienne J, Cambier E, Jadoul P, Guiot P, et al., A stratified intraoperative surgical strategy is mandatory during laparoscopic common bile duct exploration for common bile duct stones. Lessons and limits from an initial experience of 92 patients,
Surg Endosc. 11(1997) 722-728.
22 Chen XM, Zhang Y, Cai HH, Sun DL, Liu SY, Duan YF, et al., Transcystic approach with micro-incision of the cystic duct and its confluence part in laparoscopic
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common bile duct exploration, J Laparoendosc Adv Surg Tech A. 23 (2013) 977-981. 23 Kim EY, Lee SH, Lee JS, Hong TH, Laparoscopic CBD exploration using a V-shaped choledochotomy, BMC Surg. 15 (2015) 62.
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24 Tzovaras G, Baloyiannis I, Kapsoritakis A, Psychos A, Paroutoglou G, Potamianos S, Laparoendoscopic rendezvous: an effective alternative to a failed preoperative
ERCP in patients with cholecystocholedocholithiasis, Surg Endosc. 24 (2010) 2603-2606.
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25 Borzellino G, Rodella L, Saladino E, Catalano F, Politi L, Minicozzi A, et al.,
Treatment for retained common bile duct stones during laparoscopic cholecystectomy: the rendezvous technique, Arch Surg. 145 (2010) 1145-1149.
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26 Tommasi C, Bencini L, Bernini M, Naspetti R, Cavallina G, Manetti R, et al., Routine use of simultaneous laparoendoscopic approach in patients with confirmed gallbladder and bile duct stones: fit for laparoscopy fit for "rendezvous", World J Surg.
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37 (2013) 999-1005.
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Table 1 Patient characteristics Group 1
Group 2
(n=23)
(n=142)
Age (yr)
51.7±9.2
54.6±8.8
Sex (M/F)
9/14
48/94
0.62
ASA (I/II/III)
18/3/2
109/18/15
0.96
Diameter of CBD (mm)
6.6±2.74
11.3±4.59
< 0.001
Obstructive jaundice (n, %)
5(21.7%)
33(23.2%)
0.87
Abnormal LFTs (n, %)
11 (47.8%)
History of pancreatitis (n, %)
3 (13.0%)
Cholangitis (n, %)
3(13.0%)
p value
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0.81
20(14.1%)
1.000
21(14.8%)
1.000
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64 (47.8%)
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ASA: American Society of Anesthesiologists; LFTs: liver function tests.
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0.15
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Table 2 Outcomes of LCBDE Group 1
Group 2
(n=23)
(n=142)
Operation duration (min)
122.6±15.3
117.5±13.8
Postoperative stay (d)
6.3±1.6
6.5±1.2
0.48
Conversion (n, %)
1 (4.35%)
3 (2.11%)
0.45
Complications (n, %)
2 (8.70%)
4 (2.82%)
0.20
0
p value
1
Intra-abdominal infection
(n)
0 1
Bile duct stricture (n)
0
Retained stone (n, %)
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Recurrent stone (n, %)
1 3 0
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Bile leakage (n)
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(n)
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Intra-abdominal bleeding
0.11
0
2 (1.41%)
0.57
1 (4.35%)
2 (1.41%)
0.36
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HIGHLIGHTS Endoscopic CBD stone removal is still occasionally unsuccessful.
Nondilated CBD is a contraindication to choledochotomy.
Studies of LCBDE after failed endoscopic procedures in nondilated CBD are
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rare.
LCBDE as a salvage procedure is safe and feasible for failed endoscopic stone
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removal in nondilated CBD.
S1743-9191(16)00255-7
DOI:
10.1016/j.ijsu.2016.03.037
Reference:
IJSU 2681
To appear in:
International Journal of Surgery
Received Date: 12 December 2015 Revised Date:
13 March 2016
Accepted Date: 17 March 2016
Please cite this article as: Jinfeng Z, Yin Y, Chi Z, Junye G, Laparoscopic management after failed endoscopic stone removal in nondilated common bile duct, International Journal of Surgery (2016), doi: 10.1016/j.ijsu.2016.03.037. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Laparoscopic management after failed endoscopic stone removal in nondilated
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common bile duct
Running title: Laparoscopic management after failed endoscopic procedure
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Zang Jinfeng, Yuan Yin, Zhang Chi, Gao Junye
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Zang Jinfeng, M.D., Department of Hepatobiliary Surgery, Taizhou People’s Hospital, the Fifth Affiliated Hospital of Medical School of Nantong University, Taizhou 225300, Jiangsu Province, China. [email protected]
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Yuan Yin, M.D., Department of Hepatobiliary Surgery, Taizhou People’s Hospital, the Fifth Affiliated Hospital of Medical School of Nantong University, Taizhou
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225300, Jiangsu Province, China. [email protected]
Zhang Chi, M.D., Department of Hepatobiliary Surgery, Taizhou People’s Hospital,
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the Fifth Affiliated Hospital of Medical School of Nantong University, Taizhou 225300, Jiangsu Province, China. [email protected]
Gao Junye, M.D., Department of Hepatobiliary Surgery, Taizhou People’s Hospital, the Fifth Affiliated Hospital of Medical School of Nantong University Taizhou 225300, Jiangsu Province, China. [email protected]
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Corresponding author: Zang Jinfeng, Department of Hepatobiliary Surgery, Taizhou
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People’s Hospital, No. 210, Yingchun Road, Taizhou 225300, Jiangsu Province,
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China. Tel: +86-13775687933, Fax: +86-523-86225199. E-mail: [email protected]
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Laparoscopic management after failed endoscopic stone removal in
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nondilated common bile duct
ABSTRACT
Introduction: When common bile duct (CBD) stone removal by endoscopic procedure
fails, CBD exploration is an alternative procedure. However, nondilated CBD is a
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contraindication to choledochotomy. The purpose of this study was to investigate the
results of laparoscopic CBD exploration (LCBDE) following unsuccessful endoscopic
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stone removal in nondilated CBD.
Methods: From January 2011 to June 2015, we retrospectively analyzed 165 LCBDEs. Group 1 was defined as patients with nondilated CBD who underwent LCBDE after failed endoscopic stone removal. Group 2 included patients with dilated CBD who received primary LCBDE. Outcomes of LCBDE were compared between the two groups.
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Results: There were 23 patients in Group 1 and 142 in Group 2. No significant differences were observed in demographics other than CBD diameter. There was no significant difference in operating time, postoperative hospital stay, open conversion
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rate, overall postoperative complication rate, retained stone rate, and recurrence rate between the two groups.
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Conclusion: LCBDE in experienced hands is a safe and feasible option after failure of endoscopic stone removal in nondilated CBD. However, larger numbers of cases and longer follow-up are required to validate LCBDE in nondilated CBD.
Keywords: Choledocholithiasis; Laparoscopic surgery; Endoscopic surgery
1. Introduction Five to 15% of patients with gallstones have concomitant common bile duct (CBD) stones [1]. Endoscopic retrograde cholangiopancreatography (ERCP) and
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endoscopic sphincterotomy have dramatically changed the management of CBD stones. Endoscopic stone removal is quick, often painless, and is usually successful. However, there are reports of adverse effects of endoscopic sphincterotomy. These
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include pancreatitis, duodenal perforation and bleeding [2-4]. Laparoscopic CBD exploration (LCBDE) was another revolution in the minimally invasive era that came
with the development of laparoscopic cholecystectomy (LC). LCBDE can manage
gallstones and CBD stones during the same session safely and effectively with the
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advantage of minimal access. However, LCBDE is difficult, risky, and time consuming, especially in patients with nondilated CBD. Both LCBDE and endoscopic
stone removal have been used to treat CBD stones for many years. Some randomized
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clinical studies have shown that they have similar rates of stone clearance, morbidity, and mortality, while LCBDE is associated with a shorter hospital stay and is more cost-effective compared with ERCP [5-7]. In fact, LCBDE and endoscopic procedure should be considered complementary and their roles defined appropriately according to different indications.
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Despite technical innovations, structured training programs and improved endoscopic imaging, failed biliary cannulation during ERCP occurs in 5–20% of all cases [4]. When endoscopic stone removal fails, LCBDE is an acceptable choice [8,9]. However, it remains unclear whether laparoscopic management is an optimal
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alternative to patients with nondilated CBD after an unsuccessful endoscopic procedure. The purpose of this study was to present our experience of LCBDE as a
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salvage procedure for failed endoscopic stone removal in nondilated CBD.
2. Materials and methods 2.1. Patients
From January 2011 to June 2015, 165 patients with gallstones and concomitant CBD stones who underwent LC and LCBDE during the same session at Taizhou People’s Hospital (Taizhou, Jiangsu Province, China) were included in this retrospective study. Medical records, endoscopic and operative reports were retrieved from a review of inpatient files. Patients were further classified into two groups. In Group 1, 23 patients
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with nondilated CBD underwent LC and LCBDE after failed endoscopic stone removal. In Group 2, 142 patients with dilated CBD underwent LC and LCBDE. Nondilated CBD was defined as diameter <8 mm. The study was approved by the
each patient. 2.2. Operative procedure
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ethics committee of our hospital, and informed written consent was obtained from
All patients underwent preoperative blood examination, electrocardiography, chest and
abdominal
ultrasonography.
Magnetic
resonance
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X-ray,
cholangiopancreatography was performed routinely to detect CBD stones in our center. Consultant surgeons performed LCBDE. Our standard operative technique
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included abdominal access for laparoscopic exploration using two 5-mm and two 10-mm trocars. All patients underwent supraduodenal longitudinal choledochotomy and extraction of CBD stones by intraoperative choledochoscopy. We routinely performed T-tube (12–20 Fr depending on the diameter of the bile duct) drainage and cholecystectomy after CBD clearance. Choledochorraphy was carried out using
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interrupted sutures. A subhepatic drain was inserted at the end of the procedure, and removed within three postoperative days, as long as the drainage fluid was <20 ml/day and free of bile. T-tube drainage was removed after cholangiography to exclude retained CBD stones at 6 weeks after surgery. In the case of retained CBD
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stones indicated by cholangiography, we performed choledochoscopic extraction of stones via the sinus tract of the T-tube. After discharge, patients were followed up
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every 3 months during the first year and annually thereafter (with clinical evaluation, liver function tests and ultrosonography). According to the findings, we used additional imaging studies to rule out biliary stricture and recurrent CBD stones. 2.3. Statistical analysis The statistical data were analyzed using the t test, Pearson’s χ2 test or Fisher’s exact test. Data were analyzed using SPSS for Windows version 17.0 (SPSS Inc., Chicago, IL, USA). p < 0.05 was considered statistically significant.
3. Results
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3.1. Patient characteristics In Group 1, 19 patients failed ERCP because of unsuccessful biliary cannulation. Four patients underwent LCBDE because of retained CBD stones after ERCP. We
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performed emergency LCBDE in three patients with acute cholangitis. In Group 2, 21 patients required emergency LCBDE. No significant differences were identified with respect to age, gender and other medical conditions, except for CBD diameter. The
characteristics of the two treatment groups, including main preoperative biochemical
3.2. Outcome of laparoscopic procedure
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data, are shown in Table 1.
There was no mortality in the treatment groups. One patient (4.35%) in Group 1 was
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converted to open surgery and three (2.11%) in Group 2 because of marked adhesions, leading to difficult anatomy and dissection. Duration of surgery was 122.6 min in Group 1 and 117.5 min in Group 2 (p = 0.11). There was no significant difference in postoperative hospital stay between the groups (p = 0.48).
There was no difference in the overall postoperative complication rate between
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the groups (8.70% for Group 1 vs 2.82% for Group 2). One patient in Group 1 and three in Group 2 presented with bile leakage in the postoperative 3 days. All were treated conservatively. The subhepatic drain was sufficient, and no extra drainage procedures were required, and the drain was removed within 5 days after surgery.
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Intra-abdominal bleeding after surgery occurred in one patient in Group 1, which was treated conservatively. One patient in Group 2 was complicated with postoperative
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intra-abdominal infection, which was managed with intravenous antibiotics and percutaneous drainage. No patients developed biliary stricture in either group. No patients in Group 1 and two in Group 2 had retained CBD stones (diagnosed
within 6 months after operation). One case of retained stones was detected by cholangiography and successfully treated by postoperative choledochoscopy. One patient with retained stones after T-tube removal underwent ERCP, with successful stone extraction. We found recurrent CBD stones in one patient in Group 1 and two patients in Group 2. All of these recurrent CBD stones were successfully removed by ERCP. The outcomes of LCBDE are shown in Table 2.
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4. Discussion Treatment options for concomitant gallstones and CBD stones include
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single-stage cholecystectomy and CBDE or a two-stage procedure via ERCP before or after cholecystectomy. The best approach remains controversial. As no consensus has been achieved, management of CBD stones seems to be decided more by
availability of instrumentation, personnel and skills than cost-effectiveness. As
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therapeutic ERCP enters its fourth decade, short- and longer-term results are now available and some disadvantage is becoming apparent. Although the short-term complication rate of ERCP has decreased with greater experience, pancreatitis
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continues to be a problem with an incidence rate of 5% [2,3,10]. Long-term follow-up has demonstrated the late biliary complications of endoscopic sphincterotomy, including duodenobiliary reflux and high rate of recurrent CBD stones [11]. Permanent destruction of biliary sphincter after sphincterotomy results in duodenobiliary reflux and a high rate of bacterobilia [12]. Confirmed duodenobiliary
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reflux and bacterial contamination of the bile ducts are responsible for the continuing duct stone formation. Therefore, it seems that there is a good case for preserving the biliary sphincter in patients with CBD stones. Although many studies have shown that LCBDE is more cost-effective and
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beneficial for preservation of papillary function than ERCP is, conventional T-tube placement in LCBDE as an open procedure increases postoperative complications.
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The benefits of T-tube placement include decompression of the bile duct to minimize leakage, prevention of postoperative strictures, and provision of access for detection and extraction of retained stones. In our center, LCBDE with T-tube has been performed to manage CBD stones since 2005 by a single surgical team. The low rate of CBD stone recurrence and absence of biliary stricture demonstrate that this procedure can be performed with good long-term results in the treatment of CBD stones. In CBDs with normal diameter, we would rather place the T-tube conventionally as a stent and pressure-relief tool. The absence of biliary stricture and severe bile leakage in our study indicated clearly the necessity for T-Tube placement
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in such unorthodox conditions of the bile duct. However, patient discomfort caused by T-tube drainage remains the Achilles heel of this technique. Therefore, many surgeons try to perform LCBDE with primary closure, which shows a significant
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reduction in hospital stay and duration of operation with similar complication rates between LCBDE and T-tube drainage [13-15]. T-tube-free LCBDE could result in laparoscopic procedures becoming the optimal treatment for CBD stones.
Despite advances in equipment and expertise, selective cannulation of the CBD in
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ERCP remains occasionally challenging, even for an experienced endoscopist. Biliary cannulation cannot be achieved because of special anatomical features, inflammatory
processes, and periampullary diverticula. Some authors assert that low-risk patients
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undergoing failed ERCP without other complications could be successfully and safely treated by repeated ERCP if referred to an experienced high-volume endoscopy center [16]. However, repeated ERCP is bound to increase patient burden and the incidence of ERCP-related complications. As a referral hospital, our center has to admit patients with failed ERCP. In this study, unsuccessful cannulation and migration of stones
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from the CBD to intrahepatic bile duct during ERCP were the main reasons for changing surgical procedure. After failed endoscopic stone removal, two therapeutic options remain: percutaneous techniques or surgical duct exploration. In dilated bile ducts, percutaneous removal of CBD stones is a nonsurgical and
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useful option [17,18]. Kint et al. reported a series of 110 consecutive patients with percutaneous transhepatic removal of CBD stones, including 60 who underwent failed
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ERCP. Complete stone clearance was accomplished in 104 patients (94.5%) after a median of 1.6 procedures, while first-time success was achieved only in 60 patients (54.5%). Even now, percutaneous methods are still used and considered to be reliable in our center when ERCP fails in dilated bile ducts. CBD diameter <8 mm is regarded as a contraindication to LCBDE, therefore, open CBD exploration becomes the last resort when endoscopic stone removal is unsuccessful in nondilated CBD. After our mastery of LCBDE, we attempted to manage failed ERCP in nondilated CBD using a laparoscopic procedure. Performing LCBDE in nondilated CBD requires particular skills and specialized
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equipment. First, CBD stones and the biliary tree should be delineated precisely with the
help
of
reliable
imaging
techniques,
including
magnetic
resonance
cholangiopancreatography and intraoperative cholangiography. Information from
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imaging examination contributes to deciding upon the length of CBD incision and selecting the method of stone removal, which is beneficial for protecting the tender nondilated CBD. Second, care is required when choosing a T-tube of appropriate size
and performing suturing with suitable stitches. Our experience shows that the
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diameter of the T-tube is smaller and the stitching is sparser when closure is conducted in the nondilated CBD. Lastly, LCBDE involves the management of instruments and technology that are not usually handled by the surgeons themselves.
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These consist of balloon dilators, choledochoscopes, and different baskets, which demand special cooperation between surgical team members. By virtue of intraoperative choledochoscopy, stone extraction can be performed under direct vision, and the incidence of retained stones in our study was low [19]. Therefore, constructing a sophisticated laparoscopic team becomes particularly important as
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LCBDE is undertaken in the context of complex choledocholithiasis, including large stones, impacted stones, and slender CBDs. Although we prefer routine use of the transcholedochal route in LCBDE, we realize that there are some other methods that can be applied in nondilated CBD. The
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transcystic LCBDE has been championed as the best treatment for CBD stones because it avoids choledochotomy and offers the same postoperative course as LC
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does [20]. However, due to the restrictions of the transcystic route and the disappointing success rates of this method (<60%), indications for an attempt at transcystic LCBDE are limited to fewer stones, stones located distal to the cyst–CBD junction, and smaller stones [21]. Some surgeons have performed LCBDE via the confluence of the cystic duct and bile duct as it may be technically easier to remove stones and less likely to result in strictures even in nondilated CBD [22,23]. Kim et al. defined this technique as LCBDE using a V-shaped choledochotomy and believed that it may offer an option for managing patients who are not able to undergo surgical treatment due to a narrow cystic duct or CBD. In addition, the laparo-endoscopic
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rendezvous procedure appears to be a valuable method when biliary cannulation in ERCP fails [24-26]. This procedure is associated with a higher success rate, shorter hospital stay, and fewer complications with sequential ERCP and LC. The size of the
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CBD would not affect the results of treatment if some organizational problems between endoscopists, surgeons and operating room personnel were dealt with tactfully.
The present study had some limitations. It was a retrospective observational study
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and open to selection bias. This was minimized by analyzing a consecutive series of
patients who had undergone LCBDE by a single experienced laparoscopic team. The
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small sample size weakened the validity of the results.
5. Conclusion
This study demonstrates that the efficacy and safety of LCBDE are similar between the two groups. LCBDE in experienced hands is a safe and feasible option after failure of endoscopic stone removal in nondilated CBD. Although the
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preliminary results are encouraging, larger numbers of cases and longer follow-up are needed to validate LCBDE in nondilated CBD.
Conflicts of interest
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References
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The authors have no conflicts of interest to declare.
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4 Williams EJ, Taylor S, Fairclough P, Hamlyn A, Logan RF, Martin D, et al., Are we meeting the standards set for endoscopy? Results of a large-scale prospective survey of endoscopic retrograde cholangio-pancreatograph practice, Gut. 56 (2007) 821-829.
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7 Bansal VK, Misra MC, Rajan K, Kilambi R, Kumar S, Krishna A, et al., Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with concomitant gallbladder stones and common bile duct stones: a randomized controlled trial, Surg Endosc. 28 (2014) 875-885.
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13 Cai H, Sun D, Sun Y, Bai J, Zhao H, Miao Y, Primary closure following laparoscopic
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16 Swan MP, Bourke MJ, Williams SJ, Alexander S, Moss A, Hope R, et al., Failed biliary cannulation: Clinical and technical outcomes after tertiary referral endoscopic retrograde cholangiopancreatography, World J Gastroenterol. 17 (2011) 4993-4998. 17 Healy K, Chamsuddin A, Spivey J, Martin L, Nieh P, Ogan K, Percutaneous endoscopic holmium laser lithotripsy for management of complicated biliary calculi,
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common bile duct exploration, J Laparoendosc Adv Surg Tech A. 23 (2013) 977-981. 23 Kim EY, Lee SH, Lee JS, Hong TH, Laparoscopic CBD exploration using a V-shaped choledochotomy, BMC Surg. 15 (2015) 62.
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25 Borzellino G, Rodella L, Saladino E, Catalano F, Politi L, Minicozzi A, et al.,
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26 Tommasi C, Bencini L, Bernini M, Naspetti R, Cavallina G, Manetti R, et al., Routine use of simultaneous laparoendoscopic approach in patients with confirmed gallbladder and bile duct stones: fit for laparoscopy fit for "rendezvous", World J Surg.
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Table 1 Patient characteristics Group 1
Group 2
(n=23)
(n=142)
Age (yr)
51.7±9.2
54.6±8.8
Sex (M/F)
9/14
48/94
0.62
ASA (I/II/III)
18/3/2
109/18/15
0.96
Diameter of CBD (mm)
6.6±2.74
11.3±4.59
< 0.001
Obstructive jaundice (n, %)
5(21.7%)
33(23.2%)
0.87
Abnormal LFTs (n, %)
11 (47.8%)
History of pancreatitis (n, %)
3 (13.0%)
Cholangitis (n, %)
3(13.0%)
p value
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0.81
20(14.1%)
1.000
21(14.8%)
1.000
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64 (47.8%)
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ASA: American Society of Anesthesiologists; LFTs: liver function tests.
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0.15
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Table 2 Outcomes of LCBDE Group 1
Group 2
(n=23)
(n=142)
Operation duration (min)
122.6±15.3
117.5±13.8
Postoperative stay (d)
6.3±1.6
6.5±1.2
0.48
Conversion (n, %)
1 (4.35%)
3 (2.11%)
0.45
Complications (n, %)
2 (8.70%)
4 (2.82%)
0.20
0
p value
1
Intra-abdominal infection
(n)
0 1
Bile duct stricture (n)
0
Retained stone (n, %)
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Recurrent stone (n, %)
1 3 0
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Bile leakage (n)
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(n)
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Intra-abdominal bleeding
0.11
0
2 (1.41%)
0.57
1 (4.35%)
2 (1.41%)
0.36
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HIGHLIGHTS Endoscopic CBD stone removal is still occasionally unsuccessful.
Nondilated CBD is a contraindication to choledochotomy.
Studies of LCBDE after failed endoscopic procedures in nondilated CBD are
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rare.
LCBDE as a salvage procedure is safe and feasible for failed endoscopic stone
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removal in nondilated CBD.