Treatment of Common Bile Duct Stones in Sweden 1989–2006: An Observational Nationwide Study of a Paradigm Shift

Background

The preferred strategies for treatment of common bile duct stones have changed from choledochotomy with cholecystectomy to sphincterotomy with or without cholecystectomy. The aim of the present study was to compare the effectiveness of these treatment strategies on a nationwide level in Sweden.

Methods

All patients with hospital care for benign biliary diagnoses 1988–2006 were identified in Swedish registers. Patients with common bile duct stones and a first admission with choledochotomy and or endoscopic sphincterotomy from 1989 through 2006 comprised the study group. These patients were analyzed with respect to readmission for biliary diagnoses and acute pancreatitis.

Results

Incidence of open and laparoscopic choledochotomy decreased from 19.4 to 5.2, whereas endoscopic sphincterotomy increased from 5.1 to 26.1 per 100,000 inhabitants per year, respectively. Among patients treated for common bile duct stones (n?=?26,815), 60.0?% underwent cholecystectomy during the first hospital admission in 1989–1994, compared to 30.1?% in 2001–2006. The treatment strategy that included endoscopic sphincterotomy was associated with more readmissions for biliary diagnoses and increased risk for acute pancreatitis than the treatment strategy with choledochotomy. However, patients treated with endoscopic sphincterotomy and concurrent cholecystectomy at the index admission had the lowest risk of readmission.

Conclusions

Cholecystectomy has been increasingly separated from treatment of bile duct stones, and endoscopic sphincterotomy has superseded choledochotomy as a first alternative for bile duct clearance in Sweden. In patients fit for surgery, clearance of the common bile duct can be combined with cholecystectomy, as it probably reduces the need for biliary related readmissions.     

Laparoscopic surgery and the common bile duct

Many biliary tract surgeons have now reached a level of sophistication with laparoscopic cholecystectomy that they are now able to deal with the common bile duct at the same time. Preoperative endoscopic cholangiography can be reserved for cases where choledocholithiasis has a high degree of probability. This has served to decrease the number of negative studies. The surgeon has five choices regarding stones confirmed by operative cholangiography during laparoscopic cholecystectomy: (1) do nothing, hoping the stones will pass spontaneously or that a postoperative sphincterotomy with stone extraction will be successful; (2) perform a transcystic laparoscopic common bile duct exploration (best for stones less than 1 cm and distal to the cystic duct); (3) perform a laparoscopic common bile duct exploration by choledochotomy (best for large stones in patients with common bile ducts greater than 1 cm. It is also the preferred approach with stones proximal to the insertion of the cystic duct.); (4) perform an intraoperative sphincterotomy with stone extraction, either retrograde or antegrade (this approach has some proponents but has not gained popularity among the majority of surgeons); and (5) place a double lumen catheter through the cystic duct with a proximal lumen in the common bile duct and the distal lumen in the duodenum. This can be used for serial postoperative cholangiography to confirm spontaneous stone passage or falsely positive operative cholangiograms. It is useful in situations when laparoscopic common bile duct exploration equipment or surgeon expertise is not available. If stones persist, a guidewire can be introduced through the distal lumen of the catheter for a guidewire-assisted sphincterotomy. Other CBD interventions that have been reported include laparoscopic biliary bypass and resection of choledochal cysts. Malignant lesions should not be approached by a laparoscopic method except in unusual circumstances.     

"Sequential" treatment: is it the best alternative in cholecysto-choledochal lithiasis?

Laparoscopic cholecystectomy has become the treatment of choice for patients with symptomatic cholelithiasis. About 10-20% of patients with gallbladder stones may also present associated common bile duct stones. The management of the latter remains controversial because many different surgical strategies are available: laparoscopic treatment (laparoscopic common bile duct exploration), sequential endoscopic and laparoscopic treatment (endoscopic retrograde cholangiopancreatography/endoscopic sphincterotomy [ERCP/ES] prior to laparoscopic cholecystectomy), inverted sequential endoscopic-laparoscopic treatment (laparoscopic cholecystectomy followed by ERCP/ES), and combined endoscopic-laparoscopic treatment (laparoscopic cholecystectomy with intraoperative ERCP/ES). The aim of this study was to evaluate the efficacy and safety of sequential endoscopic-laparoscopic treatment in patients with cholecystocholedocholithiasis. We retrospectively analyzed the clinical, biochemical and radiological features of 552 patients operated on for cholelithiasis from 1991 to 2001. Common bile duct stones were suspected on the basis of increased serum levels of bilirubin, GOT, GPT, GGT, alkaline phosphatase; presence of jaundice; history of pancreatitis or cholangitis; dilated common bile duct (diameter > 8 mm) or common bile duct stones at hepatobiliary ultrasonography; presence of common bile duct stones at MR-cholangiography or at i.v. cholangiography. In patients with suspected common bile duct stones, preoperative ERCP was performed; if common bile duct stones were confirmed, ES was performed. When common bile duct stones were not suspected preoperatively, laparoscopic cholecystectomy was performed directly. Overall morbidity, mortality and conversion rates in the two groups were evaluated. Of 552 patients admitted for cholelithiasis, 62 (11.3%) underwent preoperative ERCP for suspected common bile duct stones. In 41 patients (66.1%) common bile duct stones were identified and ES with common bile duct stone extraction was performed in 40 patients (clearance: 97.5%). The overall morbidity was 16% (10 cases of post-ERCP acute pancreatitis); no mortality occurred. The conversion rate during subsequent laparoscopic cholecystectomy was 4.8%. In the group of patients with no suspicion of common bile duct stones, the conversion rate was 4.9%. Sequential treatment cannot be considered the best approach for patients with cholecystocholedocholithiasis because of its morbidity rate and the high rate of negative preoperative ERCP findings. Combined endoscopic-laparoscopic treatment seems to present more advantages, especially in term of morbidity, hospital stay and patient compliance and may, in future, be considered the treatment of choice for patients with cholecystocholedocholithiasis.     

十二指肠镜、腹腔镜序贯治疗胆石症2 248例分析

目的探讨十二指肠镜、腹腔镜序贯性诊治胆石症的价值. 方法回顾性分析2000年1月～2004年12月采用十二指肠镜、腹腔镜序贯性诊治方案治疗胆石症2 248例的临床资料. 结果确诊胆囊结石1 817例,胆囊结石合并胆总管结石431例.B超诊断为胆囊结石2 021例中,行术前ERCP 690例,发现胆总管结石213例;术中胆道造影(IOC)85例,发现胆总管结石10例;腹腔镜胆囊切除(LC)术后胆总管残余结石6例,并经EST治愈.B超诊断胆囊结石合并胆总管结石227例中,ERCP证实胆总管结石202例.行LC 1 817例,EST LC 395例,LBDE 36例(其中胆管一期缝合26例,T管引流10例).全组中转开腹28例(1.2%),并发症52例(2.3%). 结论十二指肠镜、腹腔镜序贯性诊治方案治疗胆石症,体现了内镜、腔镜联合应用的优势,术后残余结石率低,微创治疗成功率高.     

Laparoscopic common duct exploration in the management of choledocholithiasis

BACKGROUND: Optimal treatment strategies for addressing common duct stones at laparoscopic cholecystectomy remain controversial. The study presents the authors' experience with laparoscopic common bile duct exploration (LCBDE). METHODS: A retrospective review was performed of 71 LCBDEs performed over 5 years using either transcystic duct flushing and mechanical techniques, transcystic duct basket retreival techniques, or laparoscopic choledochotomy. RESULTS: Laparoscopic CBDE resulted in ductal clearance in 61 of 71 (85%) cases with only 1 case of unsuspected retained common duct stones and only 1 major complication. Review of the cases that did not result in common duct clearance suggests that the success rate of laparoscopic CBDE could be increased. CONCLUSIONS: Laparoscopic CBDE is an effective treatment for concurrent gallstones and common duct stones and avoids the potential morbidity of an endoscopic sphincterotomy. General surgeons with adequate training and experience can perform laparoscopic CBDE safely and effectively.     

Laparoscopic cholecystectomy. The new 'gold standard'?

Laparoscopic cholecystectomy has rapidly been adopted by surgeons, but concerns remain about its safety, the management of common bile duct stones, and the means of appropriate training. Of 647 patients referred for cholecystectomy, preoperative endoscopic retrograde cholangiography was performed in 49 (7.6%), with 27 patients (4%) undergoing sphincterotomy and stone extraction. Traditional cholecystectomy was performed in 29 patients (4.5%). Laparoscopic cholecystectomy was attempted in 618 patients and completed successfully in 600 (97.1%). Surgical trainees functioned as the primary surgeon in 70% of cases. Technical complications occurred in three patients (0.5%), including one patient with a common bile duct laceration (0.2%). Major complications occurred in 10 patients (1.6%), with no perioperative mortality. Mean postoperative hospital stay was 1 day, with return to work or full activity a mean of 8 days after surgery. Two cases of retained common bile duct stones (0.3%) were identified. We now regard laparoscopic cholecystectomy as the "gold standard" therapy for management of symptomatic cholelithiasis.     

Laparoscopic cholecystectomy combined with endoscopic sphincterotomy and stone extraction or laparoscopic choledochoscopy and electrohydraulic lithotripsy for management of cholelithiasis with choledocholithiasis

Summary Six hundred twenty-two laparoscopic cholecystectomies were performed at St. Vincent Hospital over a 14-month period. We reviewed the records of 366 of these patients who were referred to the authors. Thirty-six patients had suspected choledocholithiasis. The primary author (M.E.A.) performed 38 endoscopic retrograde cholangiopancreatography (ERCPs) on these patients for diagnosis and management. Seventeen of the 36 patients had common bile duct stones; 19 patients had negative studies. Of the 17 patients with choledocholithiasis, 15 had successful cannulation of the common bile duct, and, of these, 10 underwent laparoscopic cholecystectomy plus endoscopic sphincterotomy and extraction of the common duct stone(s). In one high-risk elderly patient, we extracted the stone from the common duct and left the gallbladder in situ. Two patients failed endoscopic cannulation and underwent open cholecystectomy with common bile duct exploration. Four additional patients, cannulated successfully, had unsuccessful endoscopic stone removal because the stones were too large or were impacted. Two of these patients underwent open cholecystectomy and common duct exploration. The two other patients underwent laparoscopic cholecystectomy and choledochoscopy through the cystic duct with the flexible choledochoscope. An electrohydraulic lithotripsy probe was then inserted through the choledochoscope to fragment the stones, and stone fragments were allowed to pass through the previously created sphincterotomy. We believe our data, supported by data in the literature, show that these alternative methods for treating choledocholithiasis are safe and effective and should be considered primary modalities for treating this condition now that laparoscopic cholecystectomy is the treatment of choice for cholelithiasis.     

Laparoscopic common bile duct exploration.

Operative common bile duct exploration, performed in conjunction with cholecystectomy, has been considered the treatment of choice for choledocholithiasis in the presence of an intact gallbladder. With the advent of laparoscopic cholecystectomy, the management of common bile duct stones has been affected. More emphasis is being placed on endoscopic sphincterotomy and options other than operative common duct exploration. Because of this increasing demand, we have developed a new technique for laparoscopic common bile duct exploration performed in the same operative setting as laparoscopic cholecystectomy. A series of five patients who successfully underwent common bile duct exploration, flexible choledochoscopy with stone extraction, and T-tube drainage, all using laparoscopic technique, is reported. Mean postoperative length of hospital stay was 4.6 days. Outpatient T-tube cholangiography was performed in all cases and revealed normal ductal anatomy with no retained stones. Follow-up ranged from 6 weeks to 4 months, and all patients were asymptomatic and had normal liver function tests.     

腹腔镜下胆总管探查术治疗胆囊结石并胆总管结石(附84例报告)

目的 :探讨用腹腔镜行胆总管探查术治疗胆石症的微创意义及可行性。方法 :分析 84例胆囊结石并胆总管结石或胆囊切除术后胆总管结石患者运用腹腔镜下胆囊切除和 (或 )胆总管切开取石术的临床资料。结果 :84例胆石症患者均在腹腔镜下完成手术 ,其中 76例行胆囊切除并胆总管切开取石T管引流术 ,8例行胆总管一期缝合术 ,术后未发生并发症。结论 :腹腔镜胆囊切除并胆总管探查术治疗胆囊结石并胆管结石技术上是安全、可行的 ,治疗效果肯定 ,微创意义明显。     

Laparoendoscopic approach to treatment of common bile duct stones

Whereas laparoscopic cholecystectomy represents the gold standard treatment for gallstones, there is no universal consensus on the optimal treatment of common bile duct (CBD) stones. The options available are various: preoperative or postoperative endoscopic retrograde cholangiography and sphincterotomy, laparoscopic transcystic CBD exploration, laparoscopic choledochotomy, and traditional open choledochotomy. A few reports describe intraoperative endoscopic clearance of the CBD. The choice of one of these methods depends on the timing of the detection of CBD stones with regard to the cholecystectomy, the expertise of the surgeon, the technology available, and the wishes of the patient. In the surgical department of the "Ospedale Casa Sollievo della Sofferenza," a large referral medical center in Italy, we perform an intraoperative endoscopic sphincterotomy in the presence of findings suspicious for CBD stones in the course of a laparoscopic cholecystectomy. The procedure is readily available thanks to the nearby presence of a skilled endoscopist and is greatly aided by the insertion of a transcystic guidewire, which makes the papilla easily identifiable by the endoscope for the spincterotomy. We have used the technique successfully in 43 of 45 patients over a 7-year period in an overall caseload of 1775 laparoscopic cholecystectomies, with no complications, minimal added operative time, and no added postoperative hospital stay. The technique allows us to completely and definitively manage CBD stones detected intraoperatively at the time of the performance of the laparoscopic cholecystectomy with no added discomfort to the patient.     

Laparoscopic transcystic bile duct stenting in the management of common bile duct stones

Background : The management of patients with common bile duct stones associated with stones in the gall bladder remains controversial. Methods : Over the three‐year period from 1996 to 1999, patients with cholelithiasis and known choledocholithiasis, or choledocholithiasis found at laparoscopic cholecystectomy, were initially treated by placing a stent across the sphincter of Oddi. The stent was pushed along a guide wire through the cystic duct and then down the common bile duct, before the cystic duct was closed. Subsequently, the stent was used to facilitate performance of a needle knife endoscopic sphincterotomy. The stent was then removed, a cholangiography was performed and the common bile duct was cleared. Patients with persistent jaundice usually had a preoperative endoscopic retrograde cholangio‐pancreatography. Results : Transcystic stenting was the ‘intention‐to‐treat’ basis of therapy for 56 of the patients. The placement of the stent only failed once when the stent became trapped in the cystic duct. Complications of the operation included: pain and jaundice (n = 2), cholangitis (n = 1), and pulmonary embolus (n = 1). The median postoperative hospitalization was 2 days (range: 1–15). Five further patients had common bile duct stones removed via a choledochotomy; a stent was placed through the choledochotomy before its closure. The selective common bile duct cannulation rate at the first endoscopic retrograde cholangio‐pancreatography, was 98%. A second endoscopic retrograde cholangio‐pancreatography was required in 15% of patients. The only complication of all the endoscopic procedures was a single case of mild cholangitis; there were no cases of pancreatitis. Conclusion : A treatment option open to all surgeons for non‐jaundiced patients with known choledocholithiasis or choledocholithiasis found at operative cholangiogram, is the transcystic stenting of the sphincter of Oddi at the time of laparoscopic cholecystectomy. At a subsequent sitting, the common bile duct can be safely cleared endoscopically using a sphincterotomy facilitated by the stent.     

Comparison of laparoscopic cholecystectomy combined with intraoperative endoscopic sphincterotomy and laparoscopic exploration of the common bile duct for cholecystocholedocholithiasis

BACKGROUND: Laparoscopic cholecystectomy (LC) combined with intraoperative endoscopic sphincterotomy (IOEST) was compared with laparoscopic exploration of the common bile duct (LCBDE) for cholecystocholedocholithiasis in an attempt tried to find the best mini-invasive treatment for the cholelithiasis and choledocholithiasis. METHODS: For this study, 234 patients with cholelithiasis and choledocholithiasis diagnosed by preoperative B-ultrasonography and intraoperative cholangiogram were divided at random into an LC-LCBDE group (141 cases) and an LC-IOEST group (93 cases). The surgical times, surgical success rates, number of stone extractions, postoperative complications, retained common bile duct stones, postoperative lengths of stay, and hospital charges were compared prospectively. RESULTS: There were no differences between the two groups in terms of surgical time, surgical success rate, number of stone extractions, postoperative complications, retained common bile duct stones, postoperative length of stay, and hospital charge. CONCLUSION: Both LC-IOEST and LC-LCBDE were shown to be safe, effective, minimally invasive treatments for cholecystocholedocholithiasis.     

Laparoscopic choledochotomy for bile duct stones

In the era of laparoscopic surgery, treatment strategies for common bile duct stones remain controversial. Laparoscopic choledochotomy is usually indicated only when transcystic duct exploration is not feasible. However, laparoscopic choledochotomy provides complete access to the ductal system and has a higher clearance rate than the transcystic approach. In addition, primary closure of the choledochotomy with a running suture and absorbable clips facilitates the procedure. Therefore, to avoid postoperative biliary stenosis, all patients with bile duct stones can be indicated for choledochotomy, except for those with nondilated common bile duct. Placement of a C-tube also provides access for the clearance of possible retained stones by endoscopic sphincterotomy as a backup procedure. C-tube placement, in contrast to T-tube insertion, is advantageous in terms of a relatively short hospital stay. In conclusion, laparoscopic choledochotomy with C-tube drainage is recommended as the treatment of choice for patients with common bile duct stones. Received: February 27, 2001 / Accepted: March 19, 2001     

Laparoscopic common bile duct exploration

In recent years, laparoscopic common bile duct exploration has become the procedure of choice in the management of choledocholithiasis in several laparoscopic centers. The increasing interest for this laparoscopic approach is due to the development of instrumentation and technique, allowing the procedure to be performed safely, and it is also the result of the revised role of endoscopic retrograde cholangiopancreatography, which has been questioned because of its cost, risk of complications and effectiveness. Many surgeons, however, are still not familiar with this technique. In this article we discuss the technique and results of laparoscopic common bile duct exploration. Both the laparoscopic transcystic approach and choledochotomy are discussed, together with the results given in the literature. When one considers the costs, morbidity, mortality and the time required before the patient can return to work, it would appear that laparoscopic cholecystectomy with common bile duct exploration is more favorable than open surgery or laparoscopic cholecystectomy with preoperative or postoperative endoscopic sphincterotomy. However, the technique requires advanced laparoscopic skills, including suturing, knot tying, the use of a choledochoscope, guidewire, dilators and balloon stone extractor. Although laparoscopic common bile duct exploration appears to be the most cost-effective method to treat common bile duct stones, it should be emphasized that this procedure is very challenging, and it should be performed by well-trained laparoscopic surgeons with experience in biliary surgery.     

The use of ERCP in the management of common bile duct stones in patients undergoing laparoscopic cholecystectomy

Summary The purpose of this study was to evaluate the indications and results of endoscopic retrograde cholangiopancreatography (ERCP) for gallstone disease since the advent of laparoscopic cholecystectomy. In our personal series of 410 consecutive cases of laparoscopic cholecystectomy, we found 17 common bile duct (CBD) stones; seven were identified by preop ERCP, nine at laparoscopy by intraoperative cholangiography, and one postop by ERCP. We have performed preop ERCP in 21 patients (5.1%); CBD stones were found in seven. Our indications for preop ERCP were elevated liver function tests, dilatation of the common duct by ultrasound, or a history of jaundice/pancreatitis, and all stones were successfully removed by endoscopic sphincterotomy. At laparoscopic cholecystectomy nine patients were found to have stones; one was treated with laparoscopic methods, four with open CBD exploration, and four by postop endoscopic sphincterotomy. Post-laparoscopic cholecystectomy, five patients underwent ERCP for pain or increased liver function tests suggestive of common duct stones. One of the five was found to have stones and these were successfully removed by endoscopic sphincterotomy. ERCP is very useful as a diagnostic and therapeutic modality in laparoscopic cholecystectomy patients with suspected CBD stones. Elevated liver function tests and dilated CBD by ultrasound are the most accurate predictors of stones. Endoscopic sphincterotomy is a more effective route, at present, for stone removal than a laparoscopic approach.     

Common bile duct stones: the role of preoperative, intraoperative, and postoperative ERCP

The indications for endoscopic retrograde cholangiopancreatography (ERCP) to demonstrate the presence of common bile duct stones has changed in the era of laparoscopic cholecystectomy. Preoperative ERCP is indicated when there is strong evidence of common bile duct stones, ie, jaundice, cholangitis, ultrasound demonstration of a common bile duct stone, and specific enzyme elevations. Preoperative ERCP is not indicated in mild gallstone pancreatitis. ERCP and endoscopic sphincterotomy as the only treatment regimen is successful in elderly patients with severe comorbid illness who have gallstones and common bile duct stones. Intraoperative ERCP does not play a role in the era of laparoscopic cholecystectomy. Transcystic common duct stone removal or laparoscopic choledochotomy is becoming the approach to common duct stones demonstrated by intraoperative cholangiography. Postoperative ERCP is indicated when intraoperative removal of common bile duct stones is unsuccessful. It is important to note that magnetic resonance cholangiography will play an increasing role and will reduce the indications and frequency of the use of ERCP.     

EST联合LC治疗胆囊结石胆总管结石

目的：探讨EST联合LC联合治疗胆囊、胆总管结石的可行性及优越性。方法：先行EST（经内镜十二指肠乳头括约肌切开术）取出胆总管结石,再行LC（腹腔镜胆囊切除术）,EST失败或不宜行EST者置ENBD（鼻胆管）再行LC+腹腔镜下胆道探查、胆道镜取石,或开腹行胆道探查术。结果：全组99例,91例LC术前EST取石成功,3例LC术后EST取石成功,3例EST取石失败。2例年龄小于15岁者未行EST改行LC+腹腔镜下经胆囊管胆道镜胆道探查取石。3例EST取石失败,改行腹腔镜下胆道探查胆道镜取石、胆总管一期缝合或T管引流+LC,或开腹胆道探查一期缝合胆总管未置T管（已置ENBD）。无严重并发症,患者均治愈出院。结论：EST联合LC联合治疗胆囊结石胆总管结石是安全、可靠的方法,软硬镜联合充分体现了“微创”治疗的优势。     

Comparison of endoscopic sphincterotomy and laparoscopic exploration of the common bile duct

BACKGROUND: Laparoscopic exploration of the common bile duct is becoming more popular, although endoscopic sphincterotomy remains the usual treatment for bile duct stones. However, loss of the biliary sphincter causes permanent duodenobiliary reflux, and recurrent stone disease and biliary neoplasia may be a consequence. METHODS: A systematic literature review was conducted to compare laparoscopic exploration with endoscopic sphincterotomy. A text word search of the Medline, Pubmed and Cochrane databases, and a manual search of the citations from these references, was used. RESULTS: Endoscopic sphincterotomy is associated with a median (range) mortality rate of 1 (0-6) per cent, compared with 1 (0-5) per cent for laparoscopic bile duct exploration. The median (range) rate of pancreatitis following endoscopic sphincterotomy is 3 (1-19) per cent; this is a rare complication after laparoscopic duct exploration. The combined morbidity rate for laparoscopic cholecystectomy and endoscopic sphincterotomy is 13 (3-16) per cent, which is greater than 8 (2-17) per cent for laparoscopic bile duct exploration. Randomized trials are few and contain relatively small numbers of patients. They show little overall difference in rates of duct clearance, but a higher mortality rate and number of hospital admissions are noted for endoscopic sphincterotomy compared with laparoscopic bile duct exploration. Endoscopic sphincterotomy is associated with recurrent stone formation (up to 16 per cent) with associated cholangitis. It is also associated with bacterobilia and chronic mucosal inflammation. The late development of bile duct cancer has been reported in up to 2 per cent of patients. CONCLUSION: Laparoscopic exploration of the common bile duct may be a better way of removing stones than endoscopic sphincterotomy plus laparoscopic cholecystectomy. :     

Laparoscopic cholecystectomy and choledocholithotomy in patients with a previous gastrectomy

BACKGROUND:

An increased incidence of cholelithiasis has been widely reported after truncal vagotomy and after gastric resection. In the early phase of patient selection, previous gastrectomy has been considered a relative contraindication to laparoscopic cholecystectomy (LC). In this study, we examined the management of LC in patients with previous gastrectomy.

STUDY DESIGN:

LC was attempted on 1,260 consecutive patients. Of these patients, 29 had a previous gastrectomy. Surgical procedures that had been performed included Billroth I gastrectomies (15), Billroth II gastrectomies (10), and total gastrectomies (4). There were 23 cases of cholelithiasis, 4 chronic cholecystitis, 2 gallbladder polyps, 1 porcelain gallbladder, and 1 gallbladder cancer. Nine patients were diagnosed with stones in their common bile duct or common hepatic duct.

RESULTS:

Preoperatively, seven of nine patients with common bile duct stones were subjected to endoscopic sphincterotomy, and the stones were removed successfully from five of these patients. In the remaining two patients, common bile duct stones were removed by laparoscopic choledocholithotomy by choledochotomy. The LC was completed in 26 patients (90%) who had undergone previous gastrectomy. In 449 patients who had previous abdominal surgery without a gastrectomy, only 4 patients (0.9%) required open surgery. In contrast, three patients (10%) with previous gastrectomy required open surgery. No major complications were recorded in this study series, and no residual or retained stones were seen during a followup period of 3 months.

CONCLUSIONS:

Clear visualization of anatomic structures and landmarks, and scrupulous hemostasis are needed to perform a safe LC in these patients. We conclude that in our study patients, a previous gastrectomy is considered an indication for LC and laparoscopic choledochotomy.     

Transcystic common bile duct exploration in the management of patients with choledocholithiasis

Common bile duct stones are found in approximately 16% of patients undergoing laparoscopic cholecystectomy. If the diagnosis of choledocholithiasis is made at the preoperative workup, it is common practice to refer the patient for endoscopic retrograde cholangiography and endoscopic sphincterotomy. However, if the diagnosis is established during intraoperative cholangiography, the surgeon is confronted with a therapeutic dilemma-that is, the choice between laparoscopic common bile duct exploration, conversion to open surgery, or postoperative endoscopic sphincterotomy. We have opted to treat patients with choledocholithiasis in only one session during the laparoscopic cholecystectomy; we use the transcystic common bile duct exploration technique employing the choledochoscope. We report our early experience in terms of success of stone removal, operative time, morbidity and mortality, and length of hospital stay. From 1992 to 2002, we performed 350 laparoscopic cholecystectomies. Selective cholangiography was used in 105 patients (30%); 40 of them were found to have common bile duct stones, for an incidence of 11.4%. Among this group, we performed laparoscopic transcystic common bile duct exploration in all but six patients. Our success rate for stone removal was 94.1% (32 of 34 patients), with only two failures related to multiple stones and impaction at the ampulla, for a conversion rate of 5.8%. The mean operative time was 120 ± 40 minutes. The morbidity rate was 8.8%, and there were no deaths. Length of hospital stay was 24 to 48 hours. Mean recovery time was 7 days, and time to return to work was 15±3 days. We concluded that most of the patients with common bile duct stones found during laparoscopic cholecystectomy could be treated successfully by means of the transcystic technique with choledochoscopy, with no increase in morbidity or mortality and a shortened hospital stay and recovery time, similar to patients who undergo only laparoscopic cholecystectomy. On the basis of our results, we recommend that this method become the primary strategy in the great majority of patients with common bile duct stones found during intraoperative cholangiography. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (poster presentation).