A Prospective Study to Compare the Outcomes After Primary Laparoscopic CBD Exploration and Laparoscopic CBD Exploration Following Failed Endoscopic Stone Extraction in Patients with Concomitant Gall Stones and Common Bile Duct Stones

Virinder K Bansal, MS, FACS, Pramod Garg, MD, DM, M C Misra, MS, FRCS, FACS, Karthik Rajan, Subodh Kumar, Atin Kumar, Ragini Kilambi

Department of Surgical Disciplines, Gastroenterology and Radiology, All India Institute of Medical sciences, New Delhi,

Background
The management of primary or recurrent CBD stones has been debatable till date. While there may be a debate as to the role of preoperative ERCP in ductal clearance, there can be no question as to its utility in dealing with the complications of CBD stones like cholangitis, pancreatitis and in the postcholecystectomy CBD stones. In the past, patients with ERCP failure were referred for open CBD exploration because of the anticipated technical difficulties due to multiple and impacted stones and the dense adhesions secondary to ERCP. However, with laparoscopic CBD exploration establishing itself as the modality of choice for exploring the CBD, these patients are also gaining access to the benefits of minimally invasive surgery. The aim of this study was, therefore, to compare the outcomes of patients undergoing primary CBD exploration and those undergoing LCBDE after ERCP failure.

Methods
The study was conducted in a single surgical unit from January 2005 to May 2012. All patients undergoing laparoscopic CBD exploration were prospectively studied and divided into two groups. Group I consisted of patients undergoing a primary laparoscopic CBD exploration and Group II consisted of patients undergoing laparoscopic CBD exploration after failed ERCP. The pre-operative status and the various intra-operative and post-operative outcomes were noted. The two groups were compared for success of the procedure, difficulty level and post-operative complications. A p value of <0.05 was taken as statistically significant.

Results
A total of 150 patients underwent laparoscopic CBD exploration over a 7 year period from January 2005 to May 2012. Of these, 86 were primary laparoscopic CBD explorations (Group I) and 64 were explorations in ERCP failed patients (Group II). Stone extraction was possible in 80.2% in Group I and 79.7% in Group II (p = 0.6). Dense adhesions and CBD injury were the cause of conversion in most of the patients. Surgery was more difficult (p= 0.003) with greater adhesions (p=0.006) and longer operative time (p= 0.02) in the ERCP failed group. There was a significantly higher number of larger stones extracted in Group II compared to Group I (59.3% & 26.7%, p <0.01). Post operatively there was no significant difference in the rate of complications between the two groups. The duration of hospital stay was however insignificant between the two groups. (4.98 ± 2.5 days and 7.69 ± 12.3 days, p = 0.2).

Conclusions
Laparoscopic CBD exploration seems a safe and feasible option in patients with failed ERCP. The conversion rate, complications and postoperative outcomes are similar to those undergoing a primary LCBDE. However, it is more difficult, with greater adhesions and requires longer operative times indicating that it may require a greater degree of technical expertise.


Session: Poster Presentation

Program Number: P360

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