The Use of a Multiple Instrument Guide to Facilitate Lcbde; Report on 119 Cases

Objective: To analyze a large LCBDE experience in a community hospital and determine the efficacy of using a new device, the Multi-channel Instrument Guide (MIG) to achieve safe, practical and effective LCBDE techniques that are applicable to virtually all cases of choledocholithiasis.
Methods: All cases of choledocholithiasis that presented to our surgical team were analyzed. An algorithm progressing from trans-cystic duct LCBDE to choledochotomy techniques was employed. Balloon catheters, stone baskets, and laser lithotripters were used under video choledochoscope guidance. The MIG was used to protect and manipulate the choledochoscope without the need for grasping forceps.
Results: 119 cases of choledocholithiasis were analyzed. 21 cases were resolved using glucagon, flushing and catheter techniques that did not require use of the choledochoscope and MIG. 98 cases were more complex. Overall, 55 of the cases were resolved using trans-cystic duct techniques. 64 cases were resolved using choledochotomy techniques. Experience lead to procedural refinements and by the second half of the study the success rate for trans-cystic duct techniques had increased from 31% to 65%. Laser lithotripsy was used in 15 patients (12%). 12 patients had a pre-op ERCP (unsuccessful at clearing all stones), and of these 7 patients had a history of previous cholecystectomy. Overall the successful stone clearance rate for LCBDE was 97%. One patient was converted to open Roux-en-Y choledochojejunsostomy.
Conclusion: The 2.8 mm choledochoscope introduced into either the cystic duct or choledochotomy using the MIG is a highly effective combination for any complex LCBDE procedure. LCBDE is not a single procedure, but rather a family of related endoscopic techniques with the objective of clearing the bile ducts of stones. In trans-cystic duct LCBDE using the MIG, the adjustable tip angle and the stiffness of the MIG were advantageous in introducing the choledochoscope. The MIG was effective in protecting the choledochoscope and allowing its manipulation without the need for grasping forceps. In choledochotomy LCBDE the MIG is again used to manipulate and protect the choledochoscope. The two additional working channels are used for enhanced irrigation to distend the bile duct and to deploy balloon catheters and larger size stone baskets, thus offering procedural enhancements. Video guidance within the biliary tree is indispensable in the use of stone baskets, balloon catheters, and laser lithotripters. It is essential in confirming final clearance of the bile ducts and in evaluating the ampulla. LCBDE using the MIG and 2.8 mm choledochoscope is an effective, organized, safe and practical procedure that can be accomplished in a community hospital

Session: Podium Presentation

Program Number: S112

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