Clinical Spotlight Review: Laparoscopic Common Bile Duct Exploration

This document was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in Dec 2017.

Corresponding Author:

Marc Zerey MD, Sansum Clinic, zerey99@gmail.com

Authors:

Stephen Haggerty MD, NorthShore University HealthSystem, shaggerty@northshore.org
William Richardson MD, Ochsner Clinic, wrichardson@ochsner.org
Byron Santos MD, Dartmouth-Hitchcock Medical Center, bfernandosantos@gmail.com
Robert Fanelli MD, Guthrie Clinic, fanelli@sswne.com
L. Michael Brunt MD, Washington University School of Medicine bruntm@wustl.edu
Dimitrios Stefanidis MD, Indiana University – Purdue University Indianapolis, dimstefa@iu.edu 

Preamble

The following clinical spotlight review regarding the laparoscopic treatment of common bile duct stones is intended for physicians who manage and treat gallbladder disease and choledocholithiasis.  It is meant to critically review these techniques and the available evidence regarding their safety and efficacy.  Provided recommendations for clinical practice are linked to the level of available evidence, and where evidence is lacking expert opinion is offered.

Disclaimer

Guidelines for clinical practice and spotlight reviews are intended to indicate preferable approaches to medical problems as established by experts in the field. These recommendations will be based on existing data or a consensus of expert opinion when little or no data are available. Spotlight reviews are applicable to all physicians who address the clinical problem(s) without regard to specialty training or interests, and are intended to convey recommendations based on a focused topic; within the defined scope of review, they indicate the preferable, but not necessarily the only acceptable approaches due to the complexity of the healthcare environment. Guidelines and recommendations are intended to be flexible. Given the wide range of specifics in any health care problem, the surgeon must always choose the course best suited to the individual patient and the variables in existence at the moment of decision.

Guidelines, spotlight reviews, and recommendations are developed under the auspices of the Society of American Gastrointestinal Endoscopic Surgeons and its various committees, and approved by the Board of Governors. Each clinical spotlight review has been systematically researched, reviewed and revised by the guidelines committee, and, when appropriate, reviewed by an appropriate multidisciplinary team. The recommendations are therefore considered valid at the time of production based on the data available.

Introduction

Choledocholithiasis complicates the management of 10-15% of patients undergoing cholecystectomy for uncomplicated, symptomatic cholelithiasis. [1-4] The ideal management of concomitant stones in the gallbladder and the common bile duct (CBD) remains controversial, as several options exist. Before the advent of laparoscopic and endoscopic methods, open cholecystectomy and CBD exploration were the standard treatment for patients with CBD stones.  The introduction of laparoscopic cholecystectomy into clinical practice in 1989 [5] ushered in a new era in the management of gallbladder and biliary disease with quicker recovery, less postoperative pain, and shorter duration of hospital stay.[6-8]

Although not favored in the “open era” for preoperative clearance of the bile duct [9, 10], endoscopic retrograde cholangiopancreatography (ERCP) is often used before or after laparoscopic cholecystectomy in patients with suspected (jaundiced patient, elevated liver function tests, history of pancreatitis, or dilated CBD on radiographic imaging)[1, 11] or confirmed CBD stones. This trend may be related to the increased technical difficulty in performing laparoscopic common bile duct exploration (LCBDE). [12]Nevertheless, while ERCP is very effective in clearing CBD stones, this management option has also a number of disadvantages, including an up to 86% normal exam rate, when performed routinely [13]. Short-term complications, while infrequent, may include pancreatitis, bleeding, perforation, and cholangitis. Further, division of the sphincter of Oddi leads to loss of this physiologic barrier, which in the long-term may lead to ampullary stenosis, duodenobiliary reflux, and recurrent stone formation.[14]

Refinements in technique and improvements in equipment have provided the tools necessary for surgeons with advanced laparoscopic training to effectively treat choledocholithiasis in a single-stage, laparoscopic procedure. [4, 15-21]

Statement of Focus

The intent of this Clinical Spotlight Review is to address a series of clinical questions relevant to the management of CBD stones by critically reviewing the available literature, and describe the techniques used for the laparoscopic treatment of common bile duct stones.

When should LCBDE be performed?

LCBDE is indicated when common bile duct stones have been demonstrated during patient workup by MRCP, ultrasound (US), or other imaging modalities, or found during intraoperative imaging (cholangiography or ultrasonography).  It is also indicated in patients with altered anatomy that would make a traditional ERCP difficult (Roux-en-Y gastric bypass).

LCBDE is contraindicated in the absence of common bile duct pathology, in patients with hemodynamic instability, or when a hostile porta hepatis is encountered intraoperatively.  Furthermore, a lack of the technical skill or resources (equipment, personnel) required to perform common duct exploration also contraindicates this procedure.

What evidence would suggest the presence of CBD stones and indicate the need for further workup?

In patients with obstructive jaundice, elevated liver function tests, history of pancreatitis, or dilated CBD on radiographic imaging, CBD stones should be suspected.  However, surgeons should be aware that up to 40-50% of patients with choledocholithiasis may not demonstrate any historical, laboratory, or radiographic evidence of common duct stones preoperatively.[22]

What skills are required to perform LCBDE?

Surgeons who perform LCBDE should have:

  1. A thorough knowledge of biliary anatomy;
  2. The ability to perform and interpret an intraoperative cholangiogram or laparoscopic US;
  3. An understanding of the different approaches to the common bile duct and which one to use for a specific situation;
  4. The ability to utilize different techniques of stone extraction (flushing, balloon extraction, basket extraction, choledochoscopy)
  5. The ability to perform intracorporeal suturing when a choledochotomy is performed

The success rate in surgeons who perform LCBDE routinely approaches 90%.[15-17, 23, 24] If a surgeon does not have the technical skills or equipment required for LCBDE, they should consider alternative options for the patient (ERCP, assistance from proficient colleague, conversion to open) depending on clinical circumstances.

What type of equipment and resources are typically necessary to perform a LCBDE?

Since specialized equipment needed to perform LCBDE are not routinely used for laparoscopic cholecystectomy, surgeons should verify that the necessary equipment is available and that the personnel are familiar with their use, prior to beginning the procedure.
Equipment and instrumentation that may be needed for LCBDE:

  1. Intraoperative fluoroscopy
  2. 5F cholangiogram catheter (to allow passage of a 0.035 inch guidewire)
  3. Vascular access sheath, typically 12F
  4. Glucagon, 1 to 2 mg, given IV by the anesthesiologist (to relax sphincter of Oddi)
  5. Fogarty-type balloon-tipped catheters; 4 Fr (for stone removal)
  6. Stone-retrieval baskets, three- or four-wire, flat, straight, in-line configuration, <1 mm total diameter.  The small diameter allows for irrigation of the CBD during manipulation.
  7. Guidewire 0.035 inches in diameter and >90 cm long (for access to common duct – exchange dilator and choledochoscope)
  8. High-pressure over-the-wire pneumatic dilator (to dilate cystic duct)
  9. IV tubing for saline instillation through the choledochoscope (for biliary endoscopy)
  10. Atraumatic grasping forceps (for choledochoscope manipulation)
  11. Flexible choledochoscope, <3.2 mm diameter; a working channel >1.1 mm is preferred in order to be able to introduce stone-retrieval basket while maintaining irrigation (for biliary endoscopy)
  12. Second camera head and light source (if using a fiberoptic choledochoscope – not necessary if using a video choledochoscope)
  13. Second monitor or picture-in-picture capability of the primary laparoscopic monitor (for biliary endoscopy)
  14. Pressurized IV-bag set-up (for biliary endoscopy)
  15. Absorbable polyglycolic acid or polydioxanone suture, size 4-0 or 5-0 (if performing choledochotomy)
  16. T tube (transductal drainage) if there is concern for CBD stricture following closure
  17. Electrohydraulic or laser lithotripter to fragment impacted stones
  18. Laparoscopic ultrasound probe
  19. Laparoscopic ligating loop to securely close cystic duct after exploration.

What are the differences in patient positioning and port placement for LCBDE compared with standard laparoscopic cholecystectomy?

Patient positioning is similar to that of laparoscopic cholecystectomy. Patient is placed supine in reverse Trendelenburg and right side up position on the operating room table to maximize exposure in the right upper quadrant. The OR table used should be compatible with X-ray. The surgeon typically stands on the patient’s left with the assistant standing on the patient’s right. If available, a second assistant stands on the patient’s left, to the surgeon’s left. If transcystic exploration is performed, the surgeon moves to the right side of the patient and the assistant remains on the patient’s left side.

To accomplish LCBDE a 5th port may be needed in addition to the standard 4-ports used for laparoscopic cholecystectomy; this port is usually placed halfway between the subxiphoid and right subcostal ports.  The choledochoscope typically requires a disposable valveless port or introducer to avoid damaging it. The trocar should be long enough to allow the tip of the choledochoscope to enter the biliary tree with minimal grasper manipulation. If a grasper is used to manipulate the choledochoscope it should be padded and atraumatic.

How should the biliary tree be evaluated in anticipation of LCBDE?

Intraoperative cholangiography or laparoscopic ultrasonography may be performed to evaluate the biliary tree. This allows assessment of biliary anatomy (size of duct, integrity, anatomic variations, presence of stones) and characterization of the stones themselves (location, size, number). Ultimately, it helps the surgeon make a decision as to the optimal approach for CBD exploration (transcystic vs transcholedochal).

1. Intraoperative cholangiogram (IOC)

Although an IOC with plain x-ray may be performed, dynamic fluoroscopy is strongly encouraged given its utility when performing CBD exploration. Studies have also suggested that it may be more time-efficient and accurate.
The IOC should be carefully inspected to evaluate the entire biliary tree. Specifically:

Cystic duct: length, tortuosity, caliber, point of insertion onto CBD

Common bile duct: Caliber, leak, obstruction, filling defects (stones vs air), contrast flow into duodenum

Common, right, left hepatic ducts: Caliber, leak, obstruction, filling defects (stones vs air), visualization of bifurcation, aberrant right sectional duct anatomy.

The right-sided ductal anatomy is important to identify during IOC because of the variability of the sectional ducts.  The right anterior sectional duct (segments 5, 8) and right posterior sectional duct (segments 6, 7) should be separately identified. Specifically, the right posterior sectional duct should be clearly defined, as its entry into the central biliary tree is variable, and may insert below the bifurcation, into the cystic duct, into the gallbladder, or into the main left duct and is vulnerable to injury during cholecystectomy. Failure to identify the right-sided ductal structures should prompt concern for aberrant anatomy or for a possible biliary injury.

Stones are suspected when the IOC demonstrates a radiolucent defect, a meniscus, dilation of the biliary tree, or failure of contrast to enter the duodenum.

2. Laparoscopic ultrasound

Laparoscopic ultrasound may be performed instead of IOC in determining biliary anatomy, including ductal sizes, stone characteristics, and ampullary and pancreatic head abnormalities that may impact the procedure. The confluence of right and left hepatic ducts as well as the cystic duct-CBD junction may be seen. The CBD is followed to the duodenum to evaluate for choledocholithiasis.

When should LCBDE be performed using the transcystic approach versus choledochotomy?

The number, location, and size of the CBD stones along with the anatomy (size, length, tortuosity) of the cystic duct influence the decision of whether a transcystic or transcholedochal approach to LCBDE is feasible.  Table 1 lists the factors that may impact the surgeon’s ability to perform LCBDE via the cystic duct or via choledochotomy and should be considered during the procedure to maximize its effectiveness for clearing CBD stones.  Small distal stones are best suited for transcystic removal after cystic duct dilation.  Large or proximal stones may require either a transcholedochal approach or lithotripsy to remove. Choledochotomy should only be considered if the common bile duct is at least 7mm in diameter to reduce the incidence of postoperative stricturing.

Table 1. Factors influencing the approach to LCBD exploration [25]

FACTORTranscysticTranscholedochal
One stone++
Multiple stones++
Stones <= 6mm diameter++
Stones > 6 mm diameter+
Intrahepatic stones+
Diameter of cystic duct < 4mm+
Diameter of cystic duct > 4mm++
Diameter of common duct < 6mm+
Diameter of common duct > 6mm++
Cystic duct entrance to CBD-lateral++
Cystic duct entrance to CBD-posterior+
Cystic duct entrance to CBD-distal+
Inflammation-mild++
Inflammation-marked+
Suturing ability-poor+
Suturing ability-good++

Improved or equivocal likelihood for success = +
Poor likelihood for success = –

Can CBD stones be cleared without using a choledochoscope?

Nonobstructing CBD stones < 4 mm in diameter are likely to pass into the duodenum spontaneously. Depending on stone size, it may be feasible to flush small stones into the duodenum. To do this, 1-2 mg of IV glucagon should be given to the patient in order to relax the sphincter of Oddi. After a short waiting period of approximately 2 minutes the biliary tree can be flushed with saline via the cholangiogram catheter, with confirmation via cholangiography of stone clearance.

How can transcystic exploration of the CBD be achieved laparoscopically?

Although laparoscopic transcystic common bile duct exploration has been shown to be less effective in stone extraction compared to a transcholedochal approach, it does avoid the risks of choledochotomy. [25-31] Stone clearance rates of up to 71% may still be achieved with a transcystic approach alone. [32]

If the initial ductotomy made for the cholangiogram was too small, it may need to be extended. In a tortuous cystic duct, the cystic duct may need to be further dissected towards the CBD with the goal of making a second ductotomy closer to the cystic duct-CBD junction. This will allow for easier passage of instruments at the time of CBD exploration.

A fifth port, when used, is placed midway between the subxiphoid and right midclavicular ports to be in-line with the bile duct. This accessory port should have no valve to prevent damage to the choledochoscope. The guidewire is threaded through the cholangiogram catheter into the CBD via the cystic ductotomy using traction on the infundibulum to help achieve an optimal angle. Under fluoroscopy, the wire should be passed into the duodenum to allow sufficient length and prevent loss of wire access. An over-the-wire pneumatic dilator can be used to dilate the cystic duct. Markers seen on fluoroscopy indicate the location of the balloon.  Using contrast within the balloon to perform the dilation under fluoroscopy allows for easy tracking of its position. Dilation is typically performed to 8-12 ATM (depending on specific balloon specifications). Ideally, the balloon should span the entire cystic duct and cross the cystic duct-common duct junction. The cystic duct is usually dilated to 5-8 mm but should not be more than the diameter of the common bile duct to avoid the risk of ductal perforation. [30, 31] The pneumatic dilator is removed being careful to keep the guidewire within the CBD. The surgeon has the option of attempting stone removal with a wire basket or Fogarty balloon under fluoroscopic guidance[33] or may proceed with biliary endoscopy using a choledochoscope.

Fogarty technique: A #4 Fogarty catheter may be used to retrieve the stone. If a guidewire is in place, this should be withdrawn. The catheter is passed into the CBD and beyond the stone. The balloon is inflated and the stone withdrawn through the cystic duct stump by retrieving the catheter. Limitations of the Fogarty technique include the possibility of further impacting the stones into the duodenum through the sphincter of Oddi causing injury, pancreatitis, or bleeding. In addition, the stones may be dragged into the common hepatic duct, making extraction more difficult.

Basket retrieval: A stone retrieval wire basket can be utilized to remove the stones under fluoroscopic guidance. Alternatively, this may be performed using biliary endoscopy.

Biliary endoscopy: The choledochoscope may be advanced two ways into the bile duct: over-the-wire, or by freely driving it in after cystic duct dilation. If done over-the-wire, the guidewire is back-loaded into the operating channel at the tip of the endoscope. The guidewire is threaded until it is seen protruding through the side access port of the endoscope. The wire is then grasped securely and the endoscope is advanced over it into the CBD (Seldinger technique). A second laparoscopic video monitor is required (or picture-in-picture capability) to see both laparoscopic and endoscopic views during choledochoscopy. Gentle manipulation of the choledochoscope may be required using an atraumatic grasper. Continuous flushing via the endoscope (by connecting it to a pressurized saline bag) is required to optimize visualization during endoscopy. The guidewire is removed following entry into the CBD. Once the stone is visualized, a stone retrieval wire basket is introduced into the CBD through the operating channel. The basket is deployed under direct visualization to capture the stone. The choledochoscope and basket are withdrawn from the CBD keeping the stone close to the endoscope and in continual view. This step is repeated until all stones have been removed.  Following stone removal, a completion cholangiogram is performed to document complete clearance of the CBD. The dilated cystic duct is closed with suture or a pre-formed looped ligature. Cholecystectomy is then completed.

Surgeons who routinely perform transcystic exploration of the CBD tend to favor biliary endoscopy rather than the Fogarty technique, given its high success rate and ability to introduce the wire basket while directly visualizing the stones within the duct. [34-36]

What is the technique for transcholedochal LCBDE?

When a transcholedochal approach is appropriate, the cystic duct is dissected and followed to the cystic duct-CBD junction. The peritoneal layer overlying the anterior surface of the supraduodenal CBD is dissected for approximately 20 mm. A choledochotomy is made longitudinally to avoid injury to the blood supply to the CBD, located at the 3 and 9 o’clock position laterally along the duct. It is often prudent to test for bile first using a free 25-gauge needle prior to cutting to avoid portal venous injury. The incision should be made with an endoknife and/or endoscopic scissors. The length of the incision should equal the diameter of the largest stone.

Once the CBD has been entered, the stones will often spontaneously spill out. It is useful to have a specimen retrieval bag in the vicinity to prevent excess spillage. Suction-irrigation may be used to flush additional stones. The CBD may be palpated with an atraumatic grasper and stones gently pushed out through the choledochotomy. A choledochoscope or fluoroscopy can be used to evaluate the ducts for residual stones. Unlike the transcystic approach, a choledochotomy allows the choledochoscope to be inserted either proximally into the common, left and right hepatic ducts or distally into the common duct. A stone retrieval wire basket can be used via the choledochoscope’s working channel to retrieve any remaining stones.

Once the CBD has been cleared of stones, the ductotomy is approximated with 4-0 or 5-0 absorbable sutures in a running or interrupted fashion.  Primary closure with or without a T-tube, external biliary drain, or biliary stent may be performed at the surgeon’s discretion and depending on the clinical situation. It should be noted, however, that a meta-analysis found that the odds ratio for complications was lower when T-tubes were not utilized. Furthermore, there was no additional benefit noted with the utilization of various biliary drains or stents.[37]

What potential problems can be encountered during transcystic or transcholedochal LCBDE?

Impacted stones

Impacted biliary tract stones, obstructing the access of a stone retrieval wire basket or Fogarty balloon can be challenging to extract. These may be successfully managed with fragmentation achieved by laser or electrohydraulic lithotripsy. In this procedure, the transducer is introduced through the working channel of the choledochoscope and placed, under direct visualization, immediately against the stone, which is then broken into small fragments and collected in the basket.[38] Alternatively, post-operative ERCP may be performed to extract the stone.

Hepatic duct stones

These usually cannot be extracted via a transcystic approach due to the angulation of the cystic duct entering the CBD and usually require a choledochotomy for removal. If the CBD diameter is less than 7mm, however, laparoscopic choledochotomy should be avoided because the rate of CBD stricturing may be higher.[27] Under these circumstances (hepatic duct stones, small CBD), ERCP may be a safer option.

Inability to clear the biliary tree

If there are retained stones that are unable to be cleared due to technical reasons, or if there is ampullary edema or distal structuring, a useful adjunct is to place an antegrade ampullary stent for decompression, allowing postoperative ERCP to be performed electively and with greater ease (facilitating cannulation). These wire-guided antegrade stents may be laparoscopically placed through a transcystic or transcholedochal approach under fluoroscopy.[39, 40] Alternatively, a surgeon may assist an endoscopist in performing intraoperative ERCP by placing a flexible guidewire across the ampulla (rendez-vous procedure).[41, 42] Open conversion remains an option but should not be performed solely to perform CBD exploration when cholecystectomy can be performed laparoscopically. The overall rate of morbidity of this approach exceeds that of the morbidity after ERCP, including the risk of unsuccessful ERCP and retained stones.[32, 43]

Should biliary drainage be performed after transcystic or transcholedochal LCBDE?

Several prospective studies have demonstrated that primary closure without intraluminal drainage is safe, cost-effective, and associated with shorter length of stay, fewer complications, and earlier return to work.[37, 44-46] Nevertheless, if there is concern of potential stricturing or increased pressure within the CBD due to inflammation, edema of the papilla, or retained common duct stones, closure may occur over a T-tube, external biliary drain, or antegrade biliary stent.

A closed suction drain adjacent to the repair may be left if there are concerns about increased risk of bile leak.

What is the postoperative management after transcystic or transcholedochal LCBDE?

Oral intake is usually restarted once the patient has recovered from anesthesia and advanced thereafter. If no drain was placed, patients are discharged home within 24 hours if there are no other clinical contraindications.

If a T-tube was placed, cholangiogram is performed 24-48h postoperatively. If normal, the drain is clamped and kept in place 10-14 days prior to removal. If contrast flow into the duodenum is abnormal or stones are present, the drain is left open for 1-2 weeks. Cholangiogram is repeated. If normal, the tube may be removed. If stones are still present, these may be removed via ERCP or with assistance from interventional radiology techniques via the T-tube.

What are the potential complications associated with LCBDE and how can they be addressed?

Complication rates for either approach may range from 5% to 15% and include:

Retained stones (0-5%) [45, 47-49]:  Completion cholangiography should always be performed to assess duct clearance. Rate of CBD stone removal failure is lower when using biliary endoscopy than the blind basket technique [49].

Impacted stone in wire basket[50]: This may occur if the stone is too large to remove through the cystic duct. Proper dilation of the cystic duct helps minimize this complication. The surgeon may remove the basket and stone by extending the cystic ductotomy to its confluence with the CBD, releasing the impacted stone.  Alternatively, the impacted stone may be extracted by making a separate choledochotomy, cutting the wire, and retrieving the basket with the stone.

Bile leak (2.3-16.7%)[15, 45, 47, 48, 51]: In patients undergoing transcystic bile duct exploration, this may occur at the cystic duct orifice, cystic duct-CBD junction or the CBD itself. It is imperative to secure the cystic duct adequately at the completion of the LCBDE. In patients undergoing the transcholedochal approach, this may result from improper reapproximation of the choledochotomy. Bile leaks usually resolve with percutaneous drainage with or without ERCP. There is no evidence that T-tubes prevent bile leaks.[44]

Bile duct stricture (0-0.8%)[52-54]: There are few studies focusing on long-term outcome and therefore, biliary strictures may be underestimated. The transcystic approach minimizes the likelihood of this complication.[30] Strictures may occur following laparoscopic choledochotomy both after primary closure or closure over a T-tube. This may require endoscopic stent placement or operative repair.

Pancreatitis (0-3%)[15, 49]: This may occur due to reflux of contrast into the pancreatic duct or obstruction due to edema at the ampulla, retained stones, or intraluminal blood clots. Treatment is dependent on the cause but may require ERCP to relieve the obstruction.

Is LCBDE superior to ERCP?

Preoperative ERCP to deal with CBD stones followed by LC is a popular option since this theoretically should clear the duct of stones and prevent distal obstruction. Unfortunately, the need for ERCP is often overestimated and may subject patients to an unnecessary procedure with its attendant complications. Diagnostic modalities such as MRCP and endoscopic ultrasonography can be used to confirm the presence of choledocholithiasis so that ERCP is performed mainly for therapeutic reasons, but may also add to costs and delays in care.  In addition, despite preoperative clearance of stones, between 2-15% of patients may still have evidence of choledocholithiasis on an IOC at the time of LC. [41, 42] Thus, the surgeon should still strongly consider performing intraoperative imaging at the time of cholecystectomy in patients who have undergone preoperative ERCP. The management of CBD stones following ERCP is controversial given that most stones are likely to pass without incident if an endoscopic sphincterotomy was performed at the time of ERCP. An attempt can be made to flush them in the duodenum. If the endoscopist expresses concerns about the success of the ERCP or if the surgeon is worried that the stones may lead to complications, then LCBDE is a reasonable option.

There have been several studies comparing LC+LCBDE (single-stage) with LC+ERCP (two-stage) for the management of common duct stones. [4, 15-21, 55-61] A Cochrane review and a meta-analysis evaluating the results from 8 and 9 randomized control trials results respectively found that there was no significant difference in the mortality and overall morbidity rates between LC+LCBDE and the LC+ERCP groups. [61, 62]Procedure-specific morbidity (e.g. bile leak, cholangitis, pancreatitis) was difficult to characterize due to a lack of standard reporting pattern of these complications.

A recent randomized control trial published by Bansal et al. found that single- and two-stage management for uncomplicated concomitant gallbladder and CBD stones had similar success and complication rates, but the single-stage strategy had shorter hospital stays, had fewer procedures, and was more cost effective.[15]

Thus, in centers that are capable of performing LCBDE, LC+LCBDE may be the optimal strategy compared to two-stage management.  Ultimately, patient selection, operator experience, available equipment, and characteristics of the biliary tree should factor in the surgeon’s decision on how best to proceed. [17, 18, 63]

Should LCBDE be performed in children?

Successful LCBDE was described in a child as early as 1997. [64]Choledocholithiasis is much less prevalent in the pediatric age group than in adults.[65] While ERCP can be safely performed either before or after LC in children with CBD stones with good results,[66] few pediatric surgical centers have the skills and age-appropriate equipment to perform LCBDE. In one study, LCBDE was performed for choledocholithiasis in 8 of 102 children undergoing cholecystectomy.[67] The stones were successfully cleared by antegrade saline flushes in 3 cases, and extracted with a 4-wire basket in another 3 patients, while 2 required postoperative ERCP. When comparing LCBDE with postoperative ERCP in a cohort of 42 children, LCBDE was associated with less major complications, shorter length of stay and decreased hospital costs. In a recent study,[68] 50 LCBDE were attempted in 168 children with stones in the common bile duct on intraoperative cholangiogram. The conversion rate was 8%, and 6% of the patients required postoperative ERCP due to a retained stone, persistent hyperbilirubinemia, and a bile leak. In summary, LCBDE can be performed in children, but the outcomes data are currently limited.

Management of choledocholithiasis following Roux-en-Y gastric bypass

Bariatric surgery is one of the most commonly performed elective surgeries in the United States.[69] Certain procedures, such as Roux-en-Y gastric bypass, restrict access to the biliary tree via endoscopy. The rapid weight loss observed after bariatric surgery leads to increased incidence of gallstone formation. Cholecystectomy is not routinely performed in those undergoing bariatric surgery[70]. This places the patient at risk for a potential stone to migrate from the gallbladder to the common bile duct. Several techniques have been described for accessing the biliary system after Roux-en-Y gastric bypass surgery. This includes per-oral ERCP using specialized endoscopes[71], percutaneous transhepatic access to the biliary tree, percutaneous or laparoscopic transgastric ERCP[72, 73], or transenteric ERCP[74]. These interventions are dependent on the availability of interventional gastroenterologic and radiologic expertise that may not be present. Laparoscopic common bile duct exploration in this patient population has been described [75] and represents an excellent option for the single-stage management of choledocholithiasis in patients who have undergone Roux-en-Y gastric bypass.

Barriers to the adoption of LCBDE

Common duct stones represent a significant disease burden that are encountered by all surgeons performing laparoscopic cholecystectomy. Despite the clinical advantages of LCBDE, a recent study using the US Nationwide Inpatient Sample found that only 7% of patients with common duct stones were treated with LCBDE as opposed to 93% with ERCP.[76] Although the reason for this discrepancy is likely multifactorial, insufficient training and lack of exposure to LCBDE likely play a significant role. LCBDE involves the management of instruments and technology that are not usually handled by the surgeon. This includes balloon dilators, stone retrieval baskets, and choledochoscopes. Performing a LCBDE also requires special coordination between surgical team members in a procedure that may be performed relatively infrequently. Finally, it requires additional time but with increasing experience, the time to perform LCBDE decreases.[50, 51] Several simulators have been developed to help improve training and shorten the learning curve.[77-80]

Conclusion

Laparoscopic common bile duct exploration is a well-established procedure that has the potential to offer single-stage management of patients with choledocholithiasis.  It has a safety profile that is comparable to ERCP plus laparoscopic cholecystectomy, while being associated with lower costs and shorter hospital stays.  Transcystic LCBDE is a safe procedure that should be within the realm of most general surgeons who perform cholecystectomy on a frequent basis.  Transcholedochal LCBDE does offer greater efficacy for stone clearance and access to the entire biliary tree, but is associated with higher complication rates compared to transcystic exploration and does require a more advanced skill set.

Disclosures

Stephen Haggerty reports teaching honorarium from RL Gore.  William Richardson has no disclosures.  Byron Santos has no disclosures.  Robert Fanelli reports Royalities from Product Development, Cook, Inc.  L. Michael Brunt has no disclosures.  Dimitrios Stefanidis has no disclosures.  Marc Zerey has no disclosures.

References

  1. Fitzgibbons, R.J., Jr. and G.C. Gardner, Laparoscopic surgery and the common bile duct. World J Surg, 2001. 25(10): p. 1317-24.
  2. Bailey, R.W., et al., Laparoscopic cholecystectomy. Experience with 375 consecutive patients. Ann Surg, 1991. 214(4): p. 531-40; discussion 540-1.
  3. Graham, S.M., et al., Laparoscopic cholecystectomy and common bile duct stones. The utility of planned perioperative endoscopic retrograde cholangiography and sphincterotomy: experience with 63 patients. Ann Surg, 1993. 218(1): p. 61-7.
  4. Collins, C., et al., A prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of choledocholithiasis revisited. Ann Surg, 2004. 239(1): p. 28-33.
  5. Litynski, G.S., Erich Muhe and the rejection of laparoscopic cholecystectomy (1985): a surgeon ahead of his time. JSLS, 1998. 2(4): p. 341-6.
  6. Kane, R.L., et al., The outcomes of elective laparoscopic and open cholecystectomies. J Am Coll Surg, 1995. 180(2): p. 136-45.
  7. Williams, L.F., Jr., et al., Comparison of laparoscopic cholecystectomy with open cholecystectomy in a single center. Am J Surg, 1993. 165(4): p. 459-65.
  8. Sawyers, J.L., Current status of conventional (open) cholecystectomy versus laparoscopic cholecystectomy. Ann Surg, 1996. 223(1): p. 1-3.
  9. Stain, S.C., et al., Choledocholithiasis. Endoscopic sphincterotomy or common bile duct exploration. Ann Surg, 1991. 213(6): p. 627-33; discussion 633-4.
  10. Heinerman, P.M., O. Boeckl, and W. Pimpl, Selective ERCP and preoperative stone removal in bile duct surgery. Ann Surg, 1989. 209(3): p. 267-72.
  11. Ponsky, J.L., Endoscopic management of common bile duct stones. World J Surg, 1992. 16(6): p. 1060-5.
  12. Fink, A.S., Current dilemmas in management of common duct stones. Surg Endosc, 1993. 7(4): p. 285-91.
  13. Shapiro, S.J., et al., Laparoscopic exploration of the common bile duct: experience in 16 selected patients. J Laparoendosc Surg, 1991. 1(6): p. 333-41.
  14. Pereira-Lima, J.C., et al., Long-term results (7 to 10 years) of endoscopic papillotomy for choledocholithiasis. Multivariate analysis of prognostic factors for the recurrence of biliary symptoms. Gastrointest Endosc, 1998. 48(5): p. 457-64.
  15. Bansal, V.K., 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, 2013.
  16. Noble, H., et al., A randomized, clinical trial to compare endoscopic sphincterotomy and subsequent laparoscopic cholecystectomy with primary laparoscopic bile duct exploration during cholecystectomy in higher risk patients with choledocholithiasis. J Laparoendosc Adv Surg Tech A, 2009. 19(6): p. 713-20.
  17. Sgourakis, G. and K. Karaliotas, Laparoscopic common bile duct exploration and cholecystectomy versus endoscopic stone extraction and laparoscopic cholecystectomy for choledocholithiasis. A prospective randomized study. Minerva Chir, 2002. 57(4): p. 467-74.
  18. Cuschieri, A., et al., E.A.E.S. multicenter prospective randomized trial comparing two-stage vs single-stage management of patients with gallstone disease and ductal calculi. Surg Endosc, 1999. 13(10): p. 952-7.
  19. Nathanson, L.K., et al., Postoperative ERCP versus laparoscopic choledochotomy for clearance of selected bile duct calculi: a randomized trial. Ann Surg, 2005. 242(2): p. 188-92.
  20. Koc, B., et al., Comparison of laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for choledocholithiasis: a prospective randomized study. Am J Surg, 2013. 206(4): p. 457-63.
  21. Liberman, M.A., et al., Cost-effective management of complicated choledocholithiasis: laparoscopic transcystic duct exploration or endoscopic sphincterotomy. J Am Coll Surg, 1996. 182(6): p. 488-94.
  22. Berci, G. and L. Morgenstern, Laparoscopic management of common bile duct stones. A multi-institutional SAGES study. Society of American Gastrointestinal Endoscopic Surgeons. Surg Endosc, 1994. 8(10): p. 1168-74; discussion 1174-5.
  23. Petelin, J.B., Laparoscopic common bile duct exploration. Surg Endosc, 2003. 17(11): p. 1705-15.
  24. Phillips, E.H., et al., Laparoscopic trans-cystic-duct common-bile-duct exploration. Surg Endosc, 1994. 8(12): p. 1389-93; discussion 1393-4.
  25. Petelin, J.B., Techniques and Cost of Common Bile Duct Exploration. Semin Laparosc Surg, 1997. 4(1): p. 23-33.
  26. Phillips, E.H., Laparoscopic transcystic duct common bile duct exploration. Surg Endosc, 1998. 12(4): p. 365-6.
  27. Vecchio, R. and B.V. MacFadyen, Laparoscopic common bile duct exploration. Langenbecks Arch Surg, 2002. 387(1): p. 45-54.
  28. Crawford, D.L. and E.H. Phillips, Laparoscopic common bile duct exploration. World J Surg, 1999. 23(4): p. 343-9.
  29. Petelin, J.B., Laparoscopic approach to common duct pathology. Am J Surg, 1993. 165(4): p. 487-91.
  30. Lyass, S. and E.H. Phillips, Laparoscopic transcystic duct common bile duct exploration. Surg Endosc, 2006. 20 Suppl 2: p. S441-5.
  31. Kroh, M. and B. Chand, Choledocholithiasis, endoscopic retrograde cholangiopancreatography, and laparoscopic common bile duct exploration. Surg Clin North Am, 2008. 88(5): p. 1019-31, vii.
  32. Grubnik, V.V., et al., Laparoscopic common bile duct exploration versus open surgery: comparative prospective randomized trial. Surg Endosc, 2012. 26(8): p. 2165-71.
  33. ElGeidie, A., et al., Laparoscopic Bile Duct Clearance Without Choledochoscopy. Surg Laparosc Endosc Percutan Tech, 2015. 25(5): p. e152-5.
  34. Topal, B., R. Aerts, and F. Penninckx, Laparoscopic common bile duct stone clearance with flexible choledochoscopy. Surg Endosc, 2007. 21(12): p. 2317-21.
  35. Gupta, N., Role of laparoscopic common bile duct exploration in the management of choledocholithiasis. World J Gastrointest Surg, 2016. 8(5): p. 376-81.
  36. Phillips, E., et al., The Role of Choledochoscopy: The Eternal Problem of How to Remove a CBD Stone. Surg Innov, 2015. 22(5): p. 540-5.
  37. Yin, Z., et al., Is the end of the T-tube drainage era in laparoscopic choledochotomy for common bile duct stones is coming? A systematic review and meta-analysis. Ann Surg, 2013. 257(1): p. 54-66.
  38. Swanstrom, L.L., Laparoscopic approaches to the common bile duct stone: transcystic bile duct exploration, choledochotomy and stone fragmentation. Baillieres Clin Gastroenterol, 1993. 7(4): p. 897-919.
  39. Martin, C.J., M.R. Cox, and L. Vaccaro, Laparoscopic transcystic bile duct stenting in the management of common bile duct stones. ANZ J Surg, 2002. 72(4): p. 258-64.
  40. Fanelli, R.D. and K.S. Gersin, Laparoscopic endobiliary stenting: a simplified approach to the management of occult common bile duct stones. J Gastrointest Surg, 2001. 5(1): p. 74-80.
  41. Morino, M., et al., Preoperative endoscopic sphincterotomy versus laparoendoscopic rendezvous in patients with gallbladder and bile duct stones. Ann Surg, 2006. 244(6): p. 889-93; discussion 893-6.
  42. Rabago, L.R., et al., Two-stage treatment with preoperative endoscopic retrograde cholangiopancreatography (ERCP) compared with single-stage treatment with intraoperative ERCP for patients with symptomatic cholelithiasis with possible choledocholithiasis. Endoscopy, 2006. 38(8): p. 779-86.
  43. Chan, E., T. Neeman, and A. Thomson, Follow-up to determine unplanned hospitalization and complications after endoscopic retrograde cholangiopancreatography. ANZ J Surg, 2016.
  44. Gurusamy, K.S., R. Koti, and B.R. Davidson, T-tube drainage versus primary closure after laparoscopic common bile duct exploration. Cochrane Database Syst Rev, 2013. 6: p. CD005641.
  45. Khaled, Y.S., et al., Laparoscopic bile duct exploration via choledochotomy followed by primary duct closure is feasible and safe for the treatment of choledocholithiasis. Surg Endosc, 2013. 27(11): p. 4164-70.
  46. Lyon, M., et al., Use of biliary stent in laparoscopic common bile duct exploration. Surg Endosc, 2015. 29(5): p. 1094-8.
  47. Alhamdani, A., et al., Primary closure of choledochotomy after emergency laparoscopic common bile duct exploration. Surg Endosc, 2008. 22(10): p. 2190-5.
  48. Stoker, M.E., Common bile duct exploration in the era of laparoscopic surgery. Arch Surg, 1995. 130(3): p. 265-8; discussion 268-9.
  49. Campagnacci, R., et al., Is laparoscopic fiberoptic choledochoscopy for common bile duct stones a fine option or a mandatory step? Surg Endosc, 2010. 24(3): p. 547-53.
  50. Zhu, J.G., et al., Learning curve and outcome of laparoscopic transcystic common bile duct exploration for choledocholithiasis. Br J Surg, 2015. 102(13): p. 1691-7.
  51. Herrero, A., et al., Does the surgeon’s experience influence the outcome of laparoscopic treatment of common bile duct stones? Surg Endosc, 2013. 27(1): p. 176-80.
  52. Campbell-Lloyd, A.J., D.J. Martin, and I.J. Martin, Long-term outcomes after laparoscopic bile duct exploration: a 5-year follow up of 150 consecutive patients. ANZ J Surg, 2008. 78(6): p. 492-4.
  53. Giurgiu, D.I., et al., Laparoscopic common bile duct exploration: long-term outcome. Arch Surg, 1999. 134(8): p. 839-43; discussion 843-4.
  54. Waage, A., et al., Long-term results from laparoscopic common bile duct exploration. Surg Endosc, 2003. 17(8): p. 1181-5.
  55. ElGeidie, A.A., M.M. ElShobary, and Y.M. Naeem, Laparoscopic exploration versus intraoperative endoscopic sphincterotomy for common bile duct stones: a prospective randomized trial. Dig Surg, 2011. 28(5-6): p. 424-31.
  56. Griniatsos, J., E. Karvounis, and A. Isla, Early versus delayed single-stage laparoscopic eradication for both gallstones and common bile duct stones in mild acute biliary pancreatitis. Am Surg, 2005. 71(8): p. 682-6.
  57. Gu, A.D., et al., Comparative evaluation of two laparoscopic procedures for treating common bile duct stones. Cell Biochem Biophys, 2011. 59(3): p. 159-64.
  58. Hong, D.F., Y. Xin, and D.W. Chen, Comparison of laparoscopic cholecystectomy combined with intraoperative endoscopic sphincterotomy and laparoscopic exploration of the common bile duct for cholecystocholedocholithiasis. Surg Endosc, 2006. 20(3): p. 424-7.
  59. Lien, H.H., et al., Laparoscopic common bile duct exploration with T-tube choledochotomy for the management of choledocholithiasis. J Laparoendosc Adv Surg Tech A, 2005. 15(3): p. 298-302.
  60. Meyer, C., et al., Management of common bile duct stones by laparoscopic cholecystectomy and endoscopic sphincterotomy: pre-, per- or postoperative sphincterotomy? Dig Surg, 1999. 16(1): p. 26-31.
  61. Alexakis, N. and S. Connor, Meta-analysis of one- vs. two-stage laparoscopic/endoscopic management of common bile duct stones. HPB (Oxford), 2012. 14(4): p. 254-9.
  62. Dasari, B.V., et al., Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev, 2013. 9: p. CD003327.
  63. Lai, E.C., et al., Endoscopic biliary drainage for severe acute cholangitis. N Engl J Med, 1992. 326(24): p. 1582-6.
  64. Newman, K.D., D.M. Powell, and G.W. Holcomb, 3rd, The management of choledocholithiasis in children in the era of laparoscopic cholecystectomy. J Pediatr Surg, 1997. 32(7): p. 1116-9.
  65. Poffenberger, C.M., et al., Cholelithiasis and its complications in children and adolescents: update and case discussion. Pediatr Emerg Care, 2012. 28(1): p. 68-76; quiz 77-8.
  66. Mah, D., et al., Management of suspected common bile duct stones in children: role of selective intraoperative cholangiogram and endoscopic retrograde cholangiopancreatography. J Pediatr Surg, 2004. 39(6): p. 808-12; discussion 808-12.
  67. Short, S.S., et al., Laparoscopic common bile duct exploration in children is associated with decreased cost and length of stay: results of a two-center analysis. J Pediatr Surg, 2013. 48(1): p. 215-20.
  68. Hill, S.J., et al., Management of the pediatric patient with choledocholithiasis in an era of advanced minimally invasive techniques. J Laparoendosc Adv Surg Tech A, 2014. 24(1): p. 38-42.
  69. Buchwald, H. and D.M. Oien, Metabolic/bariatric surgery worldwide 2011. Obes Surg, 2013. 23(4): p. 427-36.
  70. Villegas, L., et al., Is routine cholecystectomy required during laparoscopic gastric bypass? Obes Surg, 2004. 14(2): p. 206-11.
  71. Kuga, R., et al., ERCP using double-balloon enteroscopy in patients with Roux-en-Y anatomy. Dig Dis, 2008. 26(4): p. 330-5.
  72. Richardson, J.F., et al., Laparoscopic transgastric endoscopy after Roux-en-Y gastric bypass: case series and review of the literature. Am Surg, 2012. 78(10): p. 1182-6.
  73. Nguyen, N.T., et al., Laparoscopic transgastric access to the biliary tree after Roux-en-Y gastric bypass. Obes Surg, 2007. 17(3): p. 416-9.
  74. Marchesini, J.C.D., et al., Transenteric ERCP for Treatment of Choledocholithiasis After Duodenal Switch. Surg Laparosc Endosc Percutan Tech, 2017. 27(3): p. e28-e30.
  75. Tucker, O., et al., Management of choledocholithiasis after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis, 2008. 4(5): p. 674-8.
  76. Poulose, B.K., P.G. Arbogast, and M.D. Holzman, National analysis of in-hospital resource utilization in choledocholithiasis management using propensity scores. Surg Endosc, 2006. 20(2): p. 186-90.
  77. Teitelbaum, E.N., et al., A simulator-based resident curriculum for laparoscopic common bile duct exploration. Surgery, 2014. 156(4): p. 880-7, 890-3.
  78. Sanchez, A., et al., Laparoscopic common bile duct exploration four-task training model: construct validity. JSLS, 2012. 16(1): p. 10-5.
  79. Santos, B.F., et al., Development and evaluation of a laparoscopic common bile duct exploration simulator and procedural rating scale. Surg Endosc, 2012. 26(9): p. 2403-15.
  80. Sanchez, A., et al., Development of a training model for laparoscopic common bile duct exploration. JSLS, 2010. 14(1): p. 41-7.

This document was prepared and revised by The SAGES Guidelines Committee

This document was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in Dec 2017.

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Guidelines for clinical practice are intended to indicate preferable approaches to medical problems as established by experts in the field. These recommendations will be based on existing data or a consensus of expert opinion when little or no data are available. Guidelines are applicable to all physicians who address the clinical problem(s) without regard to specialty training or interests, and are intended to indicate the preferable, but not necessarily the only acceptable approaches due to the complexity of the healthcare environment. Guidelines are intended to be flexible. Given the wide range of specifics in any health care problem, the surgeon must always choose the course best suited to the individual patient and the variables in existence at the moment of decision.

Guidelines are developed under the auspices of the Society of American Gastrointestinal and Endoscopic Surgeons and its various committees, and approved by the Board of Governors. Each clinical practice guideline has been systematically researched, reviewed and revised by the guidelines committee, and reviewed by an appropriate multidisciplinary team. The recommendations are therefore considered valid at the time of its production based on the data available. Each guideline is scheduled for periodic review to allow incorporation of pertinent new developments in medical research knowledge, and practice.