Song Liang, MD PhD, Morris E Franklin, MD. The Texas Endosurgery Institute
BACKGROUND AND OBJECTIVE: Common bile duct stone as one of most frequently encountered biliary diseases was traditionally managed by choledoctomy with common bile duct exploration (CBDE) for stone removal. Despite being reported, laparoscopic CBDE has still been less favorable in clinical practice with presumption of technical difficulty in this advanced laparoscopic procedure, and popularization of ERCP. This cohort study was designed on a prospectively designed biliary procedure database of our institute to compare laparoscopic transcholedochal with transcystic routes for CBDE, and aimed at defining feasibility and safety of these two different laparoscopic CBDE approaches.
METHOD: A consecutive series of patients undergoing laparoscopic CBDE between April 1991 and May 2006 at the Texas Endosurgery Institute was identified from the Laparoscopic Biliary Procedure Database of the Texas Endosurgery Institute (LBPD-TEI). The steps for laparoscopic transcholedochal-CBDE include laparoscopically creating a 5-10mm longitudinal opening at anterior wall of the common bile duct along its axis, inserting the choledocoscope, extracting the stone(s) under direct visualization, lastly placing T-tube for postoperative drainage. The operation of laparoscopic transcystic-CBDE was performed as the following steps of cystic duct dilation, choledocoscope insertion, and stone retraction.
RESULTS: Since 1991, 374 CBDE were attempted laparoscopically following selection criteria for the procedure, and 371 (99.2%) laparoscopic CBDE were completed with a conversion rate of 0.8%. The reasons for the conversions were listed as choledochoduodenal fistulas (n=2) and entero-choledochal fistula (n=1). Of 371 cases, 277 LCBDE (74.7%) were performed transcholedochally while another 97 cases (25.3%) were done transcystically. Diagnosis of CBD stone(s) was established in 291 patients preoperatively (77.8%) by biliary system ultrasonography with laboratory tests of direct bilirubin, alkaline phosphatase, and SGOT. Additionally intraoperative cholangiogram (IOC) incidentally diagnosed CBD stone(s) in 83 patients (3.3%) undergoing laparoscopic cholecystectomy. For the transcholedochal CBDE, operating time was 140.7 ± 69.7 minutes, blood loss was 39.3 ± 47.6 ml, and multiple CBD stones (>1) were found in 231 patients (83.4%). Postoperatively 13 patients (4.7%) developed complications including pancreatitis (n=1), T-tube dislodgement (n=4), bile leakage (n=6), as well as retained stone (n=2). Length of postoperative hospitalization for the transcholedochal CBDE was 2.4 ± 1.1 days. In comparison, the operative time for the laparoscopic transcytic-CBDE was 101.6 ± 39.8 minutes, and blood loss was 26.7 ± 12.8 ml. Intraoperatively 34 laparoscopic transcystic CBD explorations were converted to transcholedochal ones due to the technical difficulty. Postoperatively the complications (2 bile leakage and 5 retained stone) were found in 7 patients with the rate of 7.2% (p=0.34), and length of hospital stay was 1.7 ± 0.9 days.
CONCLUSIONS: Laparoscopic common bile duct exploration can be performed safely and effectively for managing common bile duct stone(s) with comparable operation time, intra- and postoperative complications, and shorter hospital stays. Moreover, despite transcystic laparoscopic CBDE possessing the advantages of maintenance of intactness of common bile duct, transcholechochal CBDE has been our favorable laparoscopic approach because of its benefits in the management of multiple and large CBD stones, and significantly lowered the chance of retained stone(s).
Program Number: S103