Massimo Chiarugi, MD FACS, Christian Galatioto, MD, Piero Lippolis, MD, Luigi Decanini, MD, Adolfo Puglisi, MD, Chiara Bagnato, MD, Sonia Panicucci, MD, Marco Pelosini, MD, Pietro Iacconi, MD, Massimo Seccia, MD. Department of Surgery, University of Pisa, Pisa, Italy
INTRODUCTION Common bile duct (CBD) stones are found in near 10% of patients undergoing elective laparoscopic surgery for symptomatic gallstone disease. For these patients laparoscopic trans-cystic exploration of the common duct (LTCE) with basket catheters has proved to be a safe and effective method to obtain CBD clearance. The occurrence of CBD stones ranges from 10 to 20% in patients presenting with acute cholecystitis (AC) but in this setting little is known about the feasibility and the effectiveness of LTCE as part of a single-stage laparoscopic procedure.
METHODS AND PROCEDURES We report the results of a prospective study based on a “laparoscopy first” policy for patients with gallstone disease and CBD stones. The study, started in 2003, includes n=201 subjects (n=104 females, n= 97 males) with a mean age of 65 yrs (range 23-100). N=104 patients underwent elective laparoscopic surgery (group A) whereas n=97 were admitted on a emergency basis for AC and had urgent laparoscopic surgery within 72 hours from the admission (group B). All patients had intra-operative cholangiograms confirming the diagnosis of CBD stones. LTCE, when not contra-indicated, was carried-out by using basket-wired catheters. Groups did not differ significantly for BMI, previous abdominal surgery and clinical evidence of obstructive jaundice at the time of surgery. Group B patients however were significantly elder (means, 68.4 vs. 62.1 yrs; p=.0045), had a higher proportion of females (56 vs. 41%; p=.00345) and included more patients in the ASA III and IV classes of risk (39 vs. 21%; p=.0006). Accomplishment of CBD clearance, operating time, conversion rate, overall morbidity and mortality, postoperative hospital stay, readmission rate and occurrence of residual CBD stones were the main outcome measures. Comparisons were made on intention-to-treat basis by using a statistical software.
RESULTS Clearance of CBD was obtained in 84% of patients of group A and in 80% of patients of group B (p=ns). For those patients in which LTCE failed (n=36; 18%) alternative procedures included laparoscopic choledochotomy and ERCP, but in n=16 a laparotomy was eventually required. Time spent in the theatre was significantly longer for group B patients (means, 175 vs. 141 minutes; p=.0003). There were no significant differences for postoperative hospital stay ( means, group A 4.9 vs. group B 5.2 days), readmission rate (group A 3.7 vs. group B 3.7%) and evidence of residual CBD stones (group A 2.8 vs. group B 3.1%). Need to convert and morbidity occurred more frequently in group B (11.7 vs. 4.6% and 28.7 vs. 16.8%, respectively) but differences were not significant. In group A, one patient died from MOFS.
CONCLUSIONS Patients presenting with CBD stones synchronous to AC may benefit from LTCE in a single-stage laparoscopic procedure. LTCE has proved to be a simple technique with a high yield of CBD clearance also in the acute setting. Courses are comparable to those observed for the same procedure in elective surgery despite the fact that acute patients are more at risk for drawbacks.
Program Number: S105