Laparoscopic exploration of common bile duct in difficult choledocholithiasis

Background This review investigated the role played by laparoscopic exploration of the common bile duct (LECBD) in the management of difficult choledocholithiasis.Methods This retrospective study reviewed a prospective database of LECBD for difficult choledocholithiasis during the period 1995 to 2003.Results Of the 97 LECBDs performed in the authors center from 1995 to 2003, 25 were performed for difficult choledocholithiasis. Difficult choledocholithiasis was defined as failure of endoscopic stone retrieval for the following reasons: access and cannulation difficulty, the difficult nature of common bile duct (CBD) stones, and the presence of endoscopic retrograde cholangiopancreatography (ERCP)-related complications. There were seven unsuccessful cannulations because of previous gastrectomy (n = 5) and periampullary diverticulum (n = 2). Among the 18 patients with failed endoscopic extraction, there were 10 impacted stones, 2 incomplete stone clearances after multiple attempts, 2 type 2 Mirizzi syndromes, 1 proximal stent migration, 1 repeated post-ERCP pancreatitis, 1 situs inversus, and 1 stricture at the distal common bile duct. There were 14 male and 11 female patients with a mean age of 67.8 ± 15 years. Initial presentations included cholangitis (n = 14, 56%), biliary colic (n = 3, 12%), jaundice/deranged liver function (n = 5, 20%), cholecystitis (n = 2, 8%), and pancreatitis (n = 1, 4%). Regarding the approach for LECBD, there were 2 transcystic duct explorations and 23 choledochotomies. The mean operative time was 149.4 ± 49.3 min, and there were three conversions (12%). The stone clearance rate was 100%, and no recurrence was detected during a mean follow-up period of 16.8 months. Five complications were encountered, which included bile leak (3 patients) and wound infection (2 patients). When the results were compared with the remaining 72 LECBDs for nondifficult stones during the same period, the complication rate, conversion rate, and rate of residual stones were similar despite a longer operation time (149.4 ± 49.4 min vs 121.6 ± 50.5 min).Conclusion When ERCP is impossible or stone retrieval is incomplete, LECBD is the solution to difficult CBD stones.     

Technical aspects in the laparoscopic management of complicated common bile duct stones

The management of common bile duct (CBD) stones traditionally required open laparotomy and bile duct exploration. With the advent of endoscopic and laparoscopic technology in the latter half of last century, endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) has become the mainstream treatment for CBD stones and gallstones in most medical centers around the world. However, in certain situations, ERCP cannot be feasible because of difficult cannulation and extraction. ERCP can also be associated with potential serious complications, in particular for complicated stones requiring repeated sessions and additional maneuvers. Since our first laparoscopic exploration of the CBD (LECBD) in 1995, we now adopt the routine practice of the laparoscopic approach in dealing with endoscopically irretrievable CBD stones. The aim of this article is to describe the technical details of this approach and to review the results from our series.     

腹腔镜胆总管探查胆管一期缝合(附302例临床分析)

目的:探讨腹腔镜胆总管探查胆管一期缝合的方法、适应证和禁忌证。方法:回顾总结一期胆管缝合302例的临床资料。术后3月作静脉胆道造影或B超随访。其适应证是（1）探查阴性;（2）胆管结石取净,胆管下端通畅,无或轻中度胆管炎;（3）重症胆管炎经鼻胆管引流好转。禁忌证是（1）肝内胆管结石;（2）胆总管结石未取净;（3）重症胆管炎;（4）胆总管下端通不佳。结果:279例结石取净;20例探查阴性。发生并发症15例（5.0％）,死亡1例。平均随访4.6年（3月～9年）,无胆管狭窄。结论:多数患者腹腔镜胆总管探查后可行胆管一期缝合。     

The efficacy of preoperative endoscopic retrograde cholangiopancreatography in the detection and clearance of choledocholithiasis.

BACKGROUND AND OBJECTIVES: Endoscopic retrograde cholangiopancreaticography has been reported to have a high success rate in the detection and treatment of choledocholithiasis. Although there is growing enthusiasm for laparoscopic common bile duct clearance, many patients who present with gallbladder disease and suspected choledocholithiasis have endoscopic retrograde cholangiopancreatography performed with choledocholithiasis cleared if detected. These patients are then referred for laparoscopic cholecystectomy. The purpose of this study is to determine the efficacy of preoperative endoscopic retrograde cholangiopancreatography in the diagnosis and clearance of bile duct stones at our institution. METHODS: A retrospective review was performed of all patients at this institution who underwent preoperative endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis followed by laparoscopic cholecystectomy from January 1997 through July 1998. RESULTS: Common bile duct stones were detected endoscopically in 12 of 17 (71%) patients. We found serum bilirubin level to be the best predictor of choledocholithiasis. In 12 of 12 procedures, the endoscopist performed an endoscopic sphincterotomy with stone extraction and reported a fully cleared common bile duct. Intraoperative cholangiogram performed during subsequent cholecystectomy revealed choledocholithiasis in 4 of these 12 patients. Laparoscopic techniques successfully cleared the choledocholithiasis in 3 of these patients with open techniques necessary in the fourth. CONCLUSIONS: Our data suggests that even after presumed successful endoscopic clearance of the bile duct stones, many patients (33% in our series) still have choledocholithiasis present at the time of cholecystectomy. We recommend intraoperative cholangiography at the time of cholecystectomy even after presumed successful endoscopic retrograde cholangiopancreatography with further intervention, preferably laparoscopic, to clear the choledocholithiasis as deemed necessary.     

腹腔镜胆总管切开探查取石、T管引流治疗胆总管结石

目的 探讨腹腔镜胆总管切开探查、T管引流治疗胆总管结石的疗效。方法 配合使用胆道镜施行胆总管切开探查105例,并采用镜下缝合和打结技术常规安置T管。结果 2例胆总管探查为阴性,102例结石取净、净石率99．0％（102／103）。结论 胆总管切开探查取石、T管引流是治疗胆总管结石的安全、有效措施,可根据条件选择应用。     

LCBDE+LC与ERCP+LC治疗胆囊结石合并胆总管结石的网状Meta分析

目的 近年来,腹腔镜胆囊切除术（LC）、腹腔镜胆总管探查术（LCBDE）、内镜逆行胰胆管造影术（ERCP）普遍应用于胆系结石的治疗,本Meta分析比较了三种治疗胆囊结石合并胆管结石的手术方式的疗效及安全性,即LCBDE+LC、术前ERCP（PreERCP）+LC、术中ERCP（IntraERCP）+LC。方法 计算机检索Medline、PubMed、Cochrane Library、Embase数据库,查找1990—2019年关于LCBDE+LC、PreERCP+LC、IntraERCP+LC治疗胆囊结石合并胆总管结石的随机对照试验（RCT）研究。按照纳入与排除标准,选择文献、评价质量、提取数据,采用Stata软件进行网状Meta分析。计算累积排序概率曲线下面积（SUCRA）,用于预测各手术方式的有效性及安全性,主要结局指标为结石清除率,病死率,胰腺炎、胆漏、出血,以及中转开腹率。结果 共有19篇RCT研究纳入分析,共计2 627例患者。网状Meta分析结果显示：（1）结石清除率：IntraERCP+LC优于LCBDE+LC、PreERCP+LC,差异具有统计学意义（P＜0.05）;（2）病死率：LCBDE+LC、PreERCP+LC、IntraERCP+LC三者之间的差异均无统计学意义（P＞0.05）;（3）胰腺炎：PreERCP+LC的发生率高于LCBDE+LC、IntraERCP+LC,差异具有统计学意义（P＜0.05）;（4）出血：LCBDE+LC、PreERCP+LC、IntraERCP+LC三者之间的差异均无统计学意义（P＞0.05）;（5）胆漏：LCBDE+LC的发生率高于PreERCP+LC、IntraERCP+LC,差异具有统计学意义（P＜0.05）;（6）中转开腹率：PreERCP+LC与IntraERCP+LC、LCBDE+LC与IntraERCP+LC之间的差异均无统计学意义（P＞0.05）,而LCBDE+LC发生率高于PreERCP+LC,差异具有统计学意义（P＜0.05）。结论 LCBDE+LC、PreERCP+LC、IntraERCP+LC三种手术方式均可用于治疗胆囊结石合并胆总管结石,其中IntraERCP+LC的结石清除率最高,LCBDE+LC的胆漏风险较大,而PreERCP+LC的胰腺炎风险最高。     

腹腔镜胆总管探查术242例临床分析

目的为了探讨腹腔镜下胆总管探查术的临床应用效果。方法回顾性分析我院2007年6月~2016年6月242例腹腔镜下胆总管探查术的临床资料。术中行胆总管探查T管引流术170例,胆总管切开探查一期缝合42例,经胆囊管探查胆总管取石30例。结果本组242例患者中,手术时间70~260min,平均130min,术中失血30~460ml,平均150 ml。胆漏30例,28例经腹腔引流管引流4~7天治愈,2例形成腹腔局部积液经B超定位穿刺引流而治愈。肺部感染6例,胸腔积液4例,切口感染2例。20例术后行T管造影检查证实为胆管残余结石,经胆道镜1~4次取石后取净;2例患者胆道镜无法取出残余结石,经ERCP取出残余结石。术后第1d所有患者可下床活动,平均输液时间4~8d。结论腹腔镜下胆总管探查术是相对微创安全的手术,应根据患者具体情况采取个体化的术式。     

LAPAROSCOPIC COMMON BILE DUCT EXPLORATION

Twenty-one patients underwent laparoscopic common bile duct exploration during a 9 month period. Ten had stones flushed after ampullary dilatation. Seven had stones removed with a Dormier basket and one had direct common duct incision with T-tube insertion. Three failed attempted stone flushing and had stones removed by endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy. Operating time ranged from 1.5 to 3.5 h. Nineteen patients were discharged by the second postoperative day. This early experience with laparoscopic stone removal is encouraging, reducing the need for pre-operative or postoperative ERCP.     

Single‐stage laparoscopic cholecystectomy and intraoperative endoscopic retrograde cholangiopancreatography: is this strategy feasible in Australia?

Currently in Australasia, concomitant cholecystolithiasis and choledocholithiasis are usually managed with two procedures: laparoscopic cholecystectomy (LC) and pre or postoperative endoscopic retrograde cholangiopancreatography (ERCP). This approach exposes the patient to the risk of complications from the common bile duct stone(s) while awaiting ERCP, the risks of the ERCP itself (particularly pancreatitis) and the need for a second anaesthetic. This article explores the evidence for a newer hybrid approach, single stage LC and intraoperative ERCP (SSLCE) and compares this approach with the commonly used alternatives. SSLCE offers reduced rates of pancreatitis, reduced length of hospital stay and reduced cost compared with the two‐stage approach and requires only one anaesthetic. There is a reduced risk of bile leak compared with procedures that involve a choledochotomy, and ductal clearance rates are superior to trans‐cystic exploration and equivalent to the standard two‐stage approach. Barriers to widespread implementation relate largely to operating theatre logistics and availability of appropriate endoscopic expertise, although when bile duct stones are anticipated these issues are manageable. There is compelling justification in the literature to gather prospective evidence surrounding SSLCE in the Australian Healthcare system.     

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.     

Stone clearance and risk factors for failure in laparoscopic transcystic exploration of the common bile duct

Background Laparoscopic cholecystectomy has become a gold standard globally. At the time of surgery, 5 to 10% of patients have coexisting stones in the common bile duct (CBD). There are several alternatives in treating these patients. We have chosen to try to extract the CBD stones at the primary operation by laparoscopic transcystic CBD exploration. Methods During the years 1994–2002 laparoscopic attempt of exploration of the CBD was made in 207 patients. Data was prospectively collected in a database, and was analyzed using unconditional logistic regression for risk factor analysis. Results In 155 of the 207 patients an attempt of transcystic CBD exploration was made and it was successful in 132 cases (85%). The median operating time was 184 minutes (range 89–384 minutes) and the median postoperative hospital stay was one day (range 1–31 days). The odds ratio for failure in stone clearance among patients with a bile duct diameter greater than 6 mm was 6.90 (95% confidence interval (CI): 0.87–54.61) compared to patients with a bile duct diameter of 6 mm or less. There was a significant threefold increase in risk among patients with stones of greater than 5 mm diameter compared to patients with stones 5 mm or less. Conclusions The laparoscopic transcystic exploration of the CBD had a high frequency of stone clearance and low morbidity in the present study. Moreover, large stones are a risk factor for failure in stone clearance.     

Long-term outcomes after laparoscopic bile duct exploration: a 5-year follow up of 150 consecutive patients

Background: The treatment of common bile duct stones discovered at routine intraoperative cholangiography includes postoperative endoscopic retrograde cholangiography or intraoperative laparoscopic common bile duct exploration. Given the equivalence of short‐term outcome data for these two techniques, the choice of one over the other may be influenced by long‐term follow‐up data. We aimed to establish the long‐term outcomes following laparoscopic common bile duct exploration and compare this with endoscopic retrograde cholangiography. Methods: One hundred and fifty consecutive patients underwent laparoscopic common bile duct exploration between March 1998 and March 2006 carried out by a single surgeon. All were prospectively studied for 1 month followed by a late‐term phone questionnaire ascertaining the prevalence of adverse symptoms. Patients presented with a standardized series of questions, with reports of symptoms corroborated by review of medical records. Results: In 150 patients, operations included laparoscopic transcystic exploration (135), choledochotomy (10) and choledochoduodenostomy (2). At long‐term follow up (mean 63 months), 116 (77.3%) patients were traceable, with 24 (20.7%) reporting an episode of pain and 18 (15.5%) had more than a single episode of pain. There was no long‐term evidence of cholangitis, stricture or pancreatitis identified in any patient. Conclusion: Laparoscopic bile duct exploration appears not to increase the incidence of long‐term adverse sequelae beyond the reported prevalence of postcholecystectomy symptoms. There was no incidence of bile duct stricture, cholangitis or pancreatitis. It is a safe procedure, which obviates the need and expense of preoperative or postoperative endoscopic retrograde cholangiography in most instances.     

腹腔镜胆总管切开取石在老年胆道结石患者中的应用

目的探讨腹腔镜胆总管切开取石治疗老年胆道结石患者的有效性,安全性。方法从2007年4月至2011年12月本院共行86例腹腔镜胆总管切开取石术。将这些患者按年龄分为两组,并进行回顾性分析。老年组(≥70岁)40例,年轻组(<70岁)46例。对比两组临床特点,手术时间,住院时间,中转开放手术率,术后累计并发症发生率,残石率和死亡率。结果老年组表现出较高的麻醉评分(P=0.003)及基础疾病患病率(P<0.01),而平均手术时间,术后住院时间,中转开放手术率,残石率,并发症的发生率、死亡率,两组无显著性差异(P>0.05)。结论腹腔镜胆总管切开取石不仅对年轻胆总管结石患者安全有效,对老年患者也是一种安全有效的治疗方式。     

Laparoscopic exploration of the common bile duct through a choledochotomy: Report of three cases

This article reports three cases of totally intraabdominal laparoscopic exploration of the common bile duct via a choledochotomy with extraction of stones. The patients had failed endoscopic retrograde cholangiopancreatography (ERCP) stone extraction because of the size of the stones in two instances, and in the third, because of the presence of a duodenal diverticulum. This procedure is a promising solution to the problem of large common bile duct (CBD) stones in centers which have established laparoscopic cholecystectomy expertise.     

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).     

术中胆道造影在腹腔镜胆总管探查中的应用价值

目的:探讨术中胆道造影在腹腔镜胆总管探查中的应用价值。方法:回顾分析20例腹腔镜胆总管探查术中胆道造影的临床资料。结果:20例均获成功,其中腹腔镜胆总管探查T管引流术15例,一期缝合4例,胆总管受压纠正1例。治疗效果良好,全组无结石残留,胆漏1例、引流15d痊愈。结论:腹腔镜胆总管探查术中应用术中胆道造影术安全、可靠、避免了结石残留,具有临床推广价值。     

两种微创治疗方案治疗老年患者胆总管结石的临床对照研究

目的比较腹腔镜胆囊切除联合胆总管探查术（LC联合LCBDE）与内镜乳头切开取石联合腹腔镜胆囊切除术（EST联合LC）治疗老年患者（≥65岁）胆总管结石的临床疗效。方法2005年7月～2010年12月,胆总管直径≥8mm且既往未接受乳头括约肌切开、胆囊切除或胆道手术的110例老年胆总管结石患者,LC联合LCBDE组47例,先行LC,确认胆总管后行LCBDE,结石取净后胆道镜检查胆道系统以确认有无结石残留;EST联合LC组63例,十二指肠镜确认十二指肠乳头,常规ERCP进一步明确诊断后行EST,取石后鼻胆管引流2—5d后行LC。对两组结石清除率、术后并发症、中转开腹率及单次治疗成功率等指标进行对比,并进行随访。结果2组结石清除率、术后并发症、中转开腹率差异无显著性（P〉0．05）,而单次治疗成功率Lc联合LCBDE组显著高于EST联合LC组[87．2％（41／47）vs．68．3％（43／63）,z。=5．372,P=0．020]。所有病例随访1—3年,平均2．1年,未出现腹痛、发热及黄疸等症状,B超未见结石复发。结论LC联合LCBDE和EST联合LC都是治疗老年患者胆总管结石安全有效的方法,而在减少治疗次数方面,LC联合LCBDE更有优势。     

同一术者ERCP+LC与LECBD+LC治疗胆囊结石合并胆总管结石的对比分析

目的 比较同一术者操作的内镜下逆行性胆胰管造影+腹腔镜胆囊切除术（ERCP＋LC）和腹腔镜胆总管探查+腹腔镜胆囊切除术（LECBD+LC）两种微创手术治疗胆囊结石合并胆总管结石的临床疗效。方法 收集2017 年1 月至2018 年7 月期间香港大学深圳医院肝胆胰外科收治的胆囊结石合并胆总管结石病例102 例,患者接受同一术者操作的ERCP+LC（n=65）或LECBD+LC（n=37）,对两组手术中转率、胆总管结石清除率、手术时间、手术出血量、术后并发症发生率、住院时间等临床数据进行统计比较。结果 ERCP+LC组在手术时间[（129.88±47.91）min vs （183.54±74.75）min,P＜0.05]、住院时间[（7.15±3.14）d vs（ 10.68±5.00）d,P＜0.05]方面优于LECBD+LC组;在手术中转率、胆总管结石清除率、手术出血量、手术并发症发生率方面,两组无统计学差异（P＞0.05）。结论 ERCP+LC和LECBD+LC均是治疗胆总管结石合并胆囊结石的有效方法,应该根据患者的具体情况进行选择,术者同时熟练掌握两种方法才可能使患者获益。     

The utility of laparoscopic common bile duct exploration in the treatment of choledocholithiasis

Laparoscopic common bile duct exploration (CBDE) was performed in 24 patients over a 23-month period. Fourteen of these patients were suspected preoperatively of harboring common bile duct (CBD) calculi. Of these, endoscopic sphincterotomy was unsuccessful in eight. Laparoscopic CBDE was performed either transcystically or via a choledochotomy. In all cases, completion cholangiography demonstrated that the CBD was free of stones. All patients were sent home with drains placed in their extrahepatic biliary system. Mean hospital stay was 2.7 days. There was no mortality. The overall morbidity rate was 29.1%. It included one trocar site infection (4.1%), four cases of mild postoperative amylasemia (16.6%), and two cases of retained stones (8.3%) seen in two patients on follow-up tube cholangiography that were successfully extracted percutaneously. The authors feel that laparoscopic CBDE is a safe and effective method of CBD stone removal that offers an alternative to preoperative ERCP and sphincterotomy.     

腹腔镜胆总管探查即时缝合术的临床应用--附403例报告

目的 总结运用腹腔镜胆总管探查即时缝合术的治疗经验。方法 从1992年6月-2003年5月,运用腹腔镜胆总管探查即时缝合的手术方式(胆道镜取石术、扩张术、细导管引流术、支架术)对403例病人进行治疗。结果 381例手术获成功(94.5％),4例残石经内镜取石治愈,4例残石内镜未取净,11例胆漏经腹腔引流管或内镜鼻胆管引流治愈,2例胆囊管细导管脱落,1例胰头癌术后15d死亡。其他并发症均经非手术综合疗法治愈。结论 选择合适病例,腹腔镜胆总管探查即时缝合术是安全可行的。