Original article
Laparoscopic common bile duct exploration D. S. Y. Chan, P. A. Jain, A. Khalifa, R. Hughes and A. L. Baker Department of Surgery, Wrexham Maelor Hospital, Wrexham LL13 7TD, UK Correspondence to: Mr D. S. Y. Chan (e-mail: [email protected])
Background: Laparoscopic common bile duct exploration (LCBDE) is a safe and effective single-stage
treatment for choledocholithiasis in the elective setting. The outcomes after LCBDE in the emergency setting are unknown. The aim of this study was to compare the outcomes following elective and emergency LCBDE for choledocholithiasis. Methods: Details of all patients who underwent LCBDE for choledocholithiasis between August 2003 and August 2013 were analysed retrospectively. The primary outcome measure was common bile duct (CBD) stone clearance rate. Secondary outcome measures were conversion rate, morbidity, mortality and length of hospital stay. Results: Some 215 consecutive patients (57 male; median age 65 (range 14–92) years) underwent LCBDE. Some 121 procedures were performed electively and 94 as an emergency. Forty-five patients (48 per cent) presented with obstructive jaundice or cholangitis in the emergency LCBDE group compared with 15 (12⋅4 per cent) in the elective group (P < 0⋅001). The CBD stone clearance rate was similarly high in both groups (96 versus 96⋅7 per cent respectively; P = 0⋅557). There were no significant differences in conversion rate (6 versus 4⋅1 per cent), morbidity (5 versus 6⋅6 per cent), mortality (2 versus 0 per cent) or median length of stay (3 days) between groups. Two patients died, both following emergency LCBDE. Conclusion: LCBDE can be performed safely and effectively in both elective and emergency settings. Presented to the Association of Laparoscopic Surgeons of Great Britain and Ireland, London, UK, November 2013 Paper accepted 6 June 2014 Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9604
Introduction
Common bile duct (CBD) stones are found in 10–15 per cent of patients undergoing cholecystectomy1,2 . According to the European Association for Endoscopic Surgery, these patients should be treated even if asymptomatic3 . Treatment options include a single-stage cholecystectomy and CBD exploration, by either an open or laparoscopic (LCBDE) procedure, or a two-stage procedure via endoscopic retrograde cholangiopancreatography (ERCP) before or after cholecystectomy. The best approach remains controversial. A recent Cochrane review4 of 16 trials concluded that there were no significant differences in morbidity, mortality and failure rates between single-stage LCBDE and the two-stage endoscopic approach. However, individual trials have suggested that the single-stage procedure results in lower morbidity, shorter length of hospital stay and is more cost-effective than the two-stage approach2,5,6 , and should therefore be offered to patients with CBD stones. © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
The ideal technique of LCBDE is also widely debated. The transcystic approach has been advocated as the first-choice treatment to avoid the potential morbidity of choledochotomy7 . However, this approach is limited to patients with a wide cystic duct, small stones and is successful in only just over 50 per cent of patients7 . Traditionally, a T tube is inserted following a choledochotomy, but it has recently been found to result in a significantly longer operating time and length of hospital stay compared with primary closure8 . LCBDE via the transcholedochal approach with primary closure is safe and effective in the elective setting9,10 . However, as a significant proportion of patients with CBD stones present acutely with obstructive jaundice, cholangitis and pancreatitis, surgery during the index admission might be of value and could potentially prevent further readmissions, thus saving costs. The outcomes following emergency LCBDE are unknown and the aim of this study was, therefore, to compare outcomes after emergency or BJS
D. S. Y. Chan, P. A. Jain, A. Khalifa, R. Hughes and A. L. Baker
elective LCBDE via the transcholedochal approach with intended primary closure. Methods
Details of all patients who underwent LCBDE between August 2003 and August 2013 by a single surgeon were analysed retrospectively. Preoperative investigations included liver function tests, abdominal ultrasonography, CT as necessary and magnetic resonance cholangiopancreatography. Intraoperative data recorded included findings on cholangiography, method of closure (primary suture or T tube) and reasons for conversion. Patients were grouped according to the mode of presentation (elective or emergency). Patients in the emergency group were operated on the next available inpatient list during the index admission. The primary outcome measure was the CBD stone clearance rate. Secondary outcome measures were conversion rate, morbidity, mortality and length of hospital stay. Bile leak was defined as persistent bile drainage of greater than 50 ml/day for more than 3 days.
Statistical analysis Grouped data are expressed as median (range), with analysis using the Mann–Whitney U test. The χ2 test and Fisher’s exact test were used for analysis of categorical data. Data analysis was carried out with SPSS® version 20 (IBM, Armonk, New York, USA). Results
Between August 2003 and August 2013, 1317 patients underwent laparoscopic cholecystectomy and routine IOC. Sixteen patients (1⋅2 per cent) had stones in a non-dilated CBD. These patients did not undergo LCBDE and postoperative ERCP was performed. Some 215 patients (57 male; median age 65 (14–92) years) had a dilated CBD with CBD stones and underwent LCBDE; 94 of these were carried out as an emergency. Demographic details and presenting features are shown in Table 1. There was a significantly higher proportion of patients with obstructive jaundice and cholangitis in the emergency LCBDE group, whereas patients who underwent elective LCBDE mostly had biliary colic or acute
Operative technique Laparoscopic cholecystectomy was performed with a standard four-port technique using a 5-mm 30∘ laparoscope (Stryker, Kalamazoo, Michigan, USA). Routine transcystic intraoperative cholangiography (IOC) using X-rays was carried out in all patients undergoing laparoscopic cholecystectomy. Patients with filling defects and a CBD diameter greater than 8 mm underwent LCBDE via the transcholedochal route. A longitudinal supraduodenal choledochotomy was done using a Berci knife (Karl Storz, Tuttlingen, Germany) and microscissors. CBD stones were retrieved under vision using a flexible choledochoscope (Olympus, Tokyo, Japan) and a wire basket (Bard Medical, Murray Hill, New Jersey, USA). Following complete ductal clearance, which was confirmed via choledochoscopy, the CBD was closed with interrupted 3/0 Vicryl® sutures (Ethicon, Johnson & Johnson, Somerville, New Jersey, USA) in thin-walled ducts and continuous sutures in thick-walled ducts. A non-suction drain was left in the gallbladder bed, and was removed the following day if there was no bile leak. Laparoscopic ultrasonography and completion cholangiography were not performed.
Follow-up All patients were followed up in the outpatient clinic 6 weeks after surgery and reviewed afterwards if there were problems. No patient was lost to follow-up. © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
Demographic details of 215 patients who underwent laparoscopic common bile duct exploration
Table 1
Age (years)* Sex ratio (M : F) ASA grade I II III IV Preoperative LFTs* Bilirubin (μmol/l) ALP (units/l) Presentation Obstructive jaundice Cholangitis Acute pancreatitis Failed ERCP Acute cholecystitis with positive IOC Biliary colic with positive IOC Findings on IOC* CBD diameter (mm) No. of CBD stones
Elective (n = 121)
Emergency (n = 94)
70 (14–92) 30 : 91
61 (29–71) 27 : 67
19 (15⋅7) 83 (68⋅6) 17 (14⋅0) 2 (1⋅7)
26 (28) 52 (55) 12 (13) 4 (4)
17 (6–425) 140 (35–1171)
50 (6–513) 212 (45–1513)
15 (12⋅4) 0 (0) 13 (10⋅7) 7 (5⋅8) 22 (18⋅2)
30 (32) 15 (16) 5 (5) 3 (3) 36 (38)
64 (52⋅9)
5 (5)
10 (8–20) 2 (0–13)
12 (8–20) 1 (0–8)
P† 0⋅014‡ 0⋅492 0⋅076
< 0⋅001‡ 0⋅007‡ < 0⋅001
0⋅015‡ 0⋅369‡
Values in parentheses are percentages unless indicated otherwise; *values are median (range). ASA, American Society of Anesthesiologists; LFT, liver function test result; ALP, alkaline phosphatase; ERCP, endoscopic retrograde cholangiopancreatography; IOC, intraoperative cholangiography; CBD, common bile duct. †χ2 test, except ‡Mann–Whitney U test.
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45 40
Outcome of patients undergoing elective and emergency laparoscopic common bile duct exploration
Table 2
Elective Emergency
% of patients
35 30
Primary closure CBD clearance Conversion to open procedure Duration of surgery (min)* Morbidity Bile leak Bleeding Pneumonia Death Length of hospital stay (days)*
25 20 15 10 5 0 Normal LFTs Abnormal LFTs + USS + normal USS
USS with USS/MRCP with dilated CBD CBD stones
Results of baseline preoperative investigations in patients who had elective and emergency laparoscopic common bile duct (CBD) exploration. LFT, liver function test result; USS, abdominal ultrasound examination; MRCP, magnetic resonance cholangiopancreatography
Fig. 1
cholecystitis. The median time from admission to surgery in patients who underwent emergency LCBDE was 3 (1–7) days. Results of preoperative investigations are shown in Fig. 1. Outcomes following LCBDE are summarized in Table 2. The CBD was cleared successfully in 207 patients (96⋅3 per cent). Four patients (1⋅9 per cent) had no stones despite a dilated CBD with apparent filling defects (2 in each group). The procedure was converted to open surgery in 11 patients (5⋅1 per cent) because of adhesions/difficult anatomy (6) and impacted stones (5). Four of the patients with impacted stones required a choledochoduodenostomy owing to failure to retrieve the stones even following conversion. Four patients required ERCP after surgery to relieve the biliary obstruction. T tubes were inserted in 13 patients in the earlier part of the series, and the CBD was closed primarily in 198 patients. The overall morbidity rate was 6⋅0 per cent (13 patients). Seven patients had a persistent bile leak requiring reintervention (4 relaparoscopy, washout and resuturing of CBD; 3 ERCP). Postoperative bleeding occurred in three patients, and all required reoperation. Three patients developed pneumonia that settled with medical therapy. The overall mortality rate was 0⋅9 per cent (2 patients); both patients underwent emergency LCBDE. One was an 83-year-old woman who presented with cholangitis and developed severe pneumonia and multiple organ failure after operation. The other was a 90-year-old woman who presented with gallstone pancreatitis and died from ischaemic bowel. The overall median length © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
Elective (n = 121)
Emergency (n = 94)
112 (92⋅6) 117 (96⋅7) 5 (4⋅1) 99 (31–256) 8 (6⋅6) 4 (3⋅3) 2 (1⋅7) 2 (1⋅7) 0 (0) 3 (1–17)
86 (91) 90 (96) 6 (6) 103 (55–253) 5 (5) 3 (3) 1 (1) 1 (1) 2 (2) 3 (1–20)
P† 0⋅772‡ 0⋅557‡ 0⋅549 0⋅132§ 0⋅693 0⋅963 0⋅715 0⋅715 0⋅107 0⋅632§
Values in parentheses are percentages unless indicated otherwise; *values are median (range). CBD, common bile duct. †Fisher’s exact text, except ‡χ2 test and §Mann–Whitney U test.
of hospital stay was 3 days. There were no significant differences in outcomes between elective and emergency LCBDE. No patient was lost to follow-up at 6 weeks. Two patients developed recurrent choledocholithiasis 3 and 4 years after surgery that was cleared successfully at ERCP. One patient who underwent LCBDE with primary closure developed a mid-CBD stricture 3 months after operation, which required two sessions of endoscopic balloon dilatation; the patient remained symptom-free at 3 years of follow-up.
Discussion
The principal findings of this study were that LCBDE via the transcholedochal route can achieve successful CBD clearance rates in over 95 per cent of patients with low morbidity and mortality rates, and a median length of hospital stay of 3 days. Primary closure seems feasible and safe after both elective and emergency LCBDE. Emergency LCBDE can be performed in a timely manner with efficacy and morbidity equivalent to that of an elective procedure. These outcomes compare favourably with results from randomized trials2,5 and large case series9 – 13 . A strength of this study is that it is one of the largest series of LCBDE procedures via the transcholedochal route, with over 40 per cent as an emergency procedure. Most series10 – 12,14,15 reported the results of LCBDE in smaller cohorts; the largest published series9 in the UK of transcholedochal exploration and primary closure included 120 patients, and reported a clearance rate of 96⋅7 per cent, morbidity rate of 8⋅3 per cent and length of hospital stay of 2⋅1 days. However, over 90 per cent of the procedures were performed in the elective setting and only ten patients www.bjs.co.uk
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D. S. Y. Chan, P. A. Jain, A. Khalifa, R. Hughes and A. L. Baker
underwent emergency LCBDE. None of the 16 randomized trials analysed in the Cochrane review4 comparing surgical versus endoscopic treatment of CBD stones included more than 150 patients in the LCBDE arm. This study has also several potential limitations. This was a retrospective observational study and so open to selection bias. This was minimized by analysing a consecutive series of patients who had undergone LCBDE by a single surgeon. Patients undergoing emergency LCBDE were younger as surgery was more likely to be offered to younger patients with less co-morbidity during the index admission. Although follow-up was complete in all patients at 6 weeks after surgery, it was not the authors’ routine practice to continue long-term outpatient follow-up for individuals who had recovered well and were asymptomatic. The extremely low incidence of delayed complications after LCBDE does not justify routine long-term follow-up6 . Patients who developed problems such as recurrent calculi or strictures were referred for further endoscopic treatment and, as far as the authors are aware, only one patient developed a stricture and two developed recurrent calculi. T tubes were inserted only in the earlier part of the series and primary closure of the choledochotomy was adopted as the evidence for this technique increased8,13,16 . The transcystic route has been championed as the first-line treatment for CBD stones as it avoids a choledochotomy and recovery is similar to that among patients undergoing laparoscopic cholecystectomy alone7 . However, owing to the restrictions of the transcystic route (patent, wide, straight cystic duct with stones less than 5 mm in diameter) and the low success rates of this approach of under 60 per cent7,17 , the authors prefer routine use of the transcholedochal route. Some groups have advocated a transverse choledochotomy as it may be technically easier to perform and close, and less likely to result in strictures9 . The incidence of bile duct strictures following choledochotomy appears to be low, regardless of whether it is performed transversely or longitudinally. No biliary strictures were reported in case series of 10011 and 13713 patients when transverse or longitudinal choledochotomies respectively were performed. However, one patient (0⋅8 per cent) in a series of 120 developed a mid-duct stricture following a transverse choledochotomy9 . In the present series, only one patient (0⋅5 per cent) developed a biliary stricture 3 months after surgery. There is insufficient evidence to support one approach over the other. Bile leaks occurred in seven patients (3⋅3 per cent), and were treated by relaparoscopy for washout and resuturing of the CBD, or by ERCP. Not surprisingly, there was a significantly higher proportion of patients with obstructive jaundice and cholangitis
in the emergency LCBDE group. Surgery was offered to these patients during the index emergency admission and LCBDE performed on the next available inpatient operating list to prevent further readmissions; this could ultimately lead to cost savings. The limited provision of ERCP compared with the demand was an important factor that led the authors to offer one-stage surgery during the index admission. As the evidence supporting LCBDE and primary suture increases, patients with choledocholithiasis will expect to be offered this single-stage approach. LCBDE is a technically demanding procedure with a long learning curve and should be performed by skilled surgeons or under close supervision with appropriate training18 .
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Disclosure
The authors declare no conflict of interest. References 1 Williams EJ, Green J, Beckingham I, Parks R, Martin D, Lombard M; British Society of Gastroenterology. Guidelines on the management of common bile duct stones (CBDS). Gut 2008; 57: 1004–1021. 2 Koc B, Karahan S, Adas G, Tutal F, Guven H, Ozsoy A. 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: 457–463. 3 Scientific Committee of the European Association for Endoscopic Surgery (E.A.E.S.). Diagnosis and treatment of common bile duct stones (CBDS). Results of a consensus development conference. Surg Endosc 1998; 12: 856–864. 4 Dasari BV, Tan CJ, Gurusamy KS, Martin DJ, Kirk G, McKie L et al. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev 2013; (12)CD003327. 5 Rogers SJ, Cello JP, Horn JK, Siperstein AE, Schecter WP, Campbell AR et al. Prospective randomized trial of LC + LCBDE vs ERCP/S + LC for common bile duct stone disease. Arch Surg 2010; 145: 28–33. 6 Bansal VK, Misra MC, Rajan K, Kilambi R, Kumar S, Krishna A 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 2014; 28: 875–885. 7 Hanif F, Ahmed Z, Samie MA, Nassar AH. Laparoscopic transcystic bile duct exploration: the treatment of first choice for common bile duct stones. Surg Endosc 2010; 24: 1552–1556.
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8 Gurusamy KS, Koti R, Davidson BR. T-tube drainage versus primary closure after laparoscopic common bile duct exploration. Cochrane Database Syst Rev 2013; (6)CD005641. 9 Khaled YS, Malde DJ, de Souza C, Kalia A, Ammori BJ. Laparoscopic bile duct exploration via choledochotomy followed by primary duct closure is feasible and safe for the treatment of choledocholithiasis. Surg Endosc 2013; 27: 4164–4170. 10 Savita KS, Bhartia VK. Laparoscopic CBD Exploration. Indian J Surg 2010; 72: 395–399. 11 Decker G, Borie F, Millat B, Berthou J, Deleuze A, Drouard F et al. One hundred laparoscopic choledochotomies with primary closure of the common bile duct. Surg Endosc 2003; 17: 12–18. 12 Thompson MH, Tranter SE. All-comers policy for laparoscopic exploration of the common bile duct. Br J Surg 2002; 89: 1608–1612. 13 Cai H, Sun D, Sun Y, Bai J, Zhao H, Miao Y. Primary closure following laparoscopic common bile duct exploration combined with intraoperative cholangiography and choledochoscopy. World J Surg 2012; 36: 164–170.
14 Lee HM, Min SK, Lee HK. Long-term results of laparoscopic common bile duct exploration by choledochotomy for choledocholithiasis: 15-year experience from a single center. Ann Surg Treat Res 2014; 86: 1–6. 15 Rojas-Ortega S, Arizpe-Bravo D, Marín López ER, Cesin-Sánchez R, Roman GR, Gomez C. Transcystic common bile duct exploration in the management of patients with choledocholithiasis. J Gastrointest Surg 2003; 7: 492–496. 16 Yin Z, Xu K, Sun J, Zhang J, Xiao Z, Wang J 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: 54–66. 17 Gigot JF, Navez B, Etienne J, Cambier E, Jadoul P, Guiot P. A stratified intraoperative surgical strategy is mandatory during laparoscopic common bile duct exploration for common bile duct stones. Surg Endosc 1997; 11: 722–728. 18 Tutton MG, Pawa N, Arulampalam TH, Motson RW. Training higher surgical trainees in laparoscopic common bile duct exploration. World J Surg 2010; 34: 569–573.
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Laparoscopic common bile duct exploration D. S. Y. Chan, P. A. Jain, A. Khalifa, R. Hughes and A. L. Baker Department of Surgery, Wrexham Maelor Hospital, Wrexham LL13 7TD, UK Correspondence to: Mr D. S. Y. Chan (e-mail: [email protected])
Background: Laparoscopic common bile duct exploration (LCBDE) is a safe and effective single-stage
treatment for choledocholithiasis in the elective setting. The outcomes after LCBDE in the emergency setting are unknown. The aim of this study was to compare the outcomes following elective and emergency LCBDE for choledocholithiasis. Methods: Details of all patients who underwent LCBDE for choledocholithiasis between August 2003 and August 2013 were analysed retrospectively. The primary outcome measure was common bile duct (CBD) stone clearance rate. Secondary outcome measures were conversion rate, morbidity, mortality and length of hospital stay. Results: Some 215 consecutive patients (57 male; median age 65 (range 14–92) years) underwent LCBDE. Some 121 procedures were performed electively and 94 as an emergency. Forty-five patients (48 per cent) presented with obstructive jaundice or cholangitis in the emergency LCBDE group compared with 15 (12⋅4 per cent) in the elective group (P < 0⋅001). The CBD stone clearance rate was similarly high in both groups (96 versus 96⋅7 per cent respectively; P = 0⋅557). There were no significant differences in conversion rate (6 versus 4⋅1 per cent), morbidity (5 versus 6⋅6 per cent), mortality (2 versus 0 per cent) or median length of stay (3 days) between groups. Two patients died, both following emergency LCBDE. Conclusion: LCBDE can be performed safely and effectively in both elective and emergency settings. Presented to the Association of Laparoscopic Surgeons of Great Britain and Ireland, London, UK, November 2013 Paper accepted 6 June 2014 Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9604
Introduction
Common bile duct (CBD) stones are found in 10–15 per cent of patients undergoing cholecystectomy1,2 . According to the European Association for Endoscopic Surgery, these patients should be treated even if asymptomatic3 . Treatment options include a single-stage cholecystectomy and CBD exploration, by either an open or laparoscopic (LCBDE) procedure, or a two-stage procedure via endoscopic retrograde cholangiopancreatography (ERCP) before or after cholecystectomy. The best approach remains controversial. A recent Cochrane review4 of 16 trials concluded that there were no significant differences in morbidity, mortality and failure rates between single-stage LCBDE and the two-stage endoscopic approach. However, individual trials have suggested that the single-stage procedure results in lower morbidity, shorter length of hospital stay and is more cost-effective than the two-stage approach2,5,6 , and should therefore be offered to patients with CBD stones. © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
The ideal technique of LCBDE is also widely debated. The transcystic approach has been advocated as the first-choice treatment to avoid the potential morbidity of choledochotomy7 . However, this approach is limited to patients with a wide cystic duct, small stones and is successful in only just over 50 per cent of patients7 . Traditionally, a T tube is inserted following a choledochotomy, but it has recently been found to result in a significantly longer operating time and length of hospital stay compared with primary closure8 . LCBDE via the transcholedochal approach with primary closure is safe and effective in the elective setting9,10 . However, as a significant proportion of patients with CBD stones present acutely with obstructive jaundice, cholangitis and pancreatitis, surgery during the index admission might be of value and could potentially prevent further readmissions, thus saving costs. The outcomes following emergency LCBDE are unknown and the aim of this study was, therefore, to compare outcomes after emergency or BJS
D. S. Y. Chan, P. A. Jain, A. Khalifa, R. Hughes and A. L. Baker
elective LCBDE via the transcholedochal approach with intended primary closure. Methods
Details of all patients who underwent LCBDE between August 2003 and August 2013 by a single surgeon were analysed retrospectively. Preoperative investigations included liver function tests, abdominal ultrasonography, CT as necessary and magnetic resonance cholangiopancreatography. Intraoperative data recorded included findings on cholangiography, method of closure (primary suture or T tube) and reasons for conversion. Patients were grouped according to the mode of presentation (elective or emergency). Patients in the emergency group were operated on the next available inpatient list during the index admission. The primary outcome measure was the CBD stone clearance rate. Secondary outcome measures were conversion rate, morbidity, mortality and length of hospital stay. Bile leak was defined as persistent bile drainage of greater than 50 ml/day for more than 3 days.
Statistical analysis Grouped data are expressed as median (range), with analysis using the Mann–Whitney U test. The χ2 test and Fisher’s exact test were used for analysis of categorical data. Data analysis was carried out with SPSS® version 20 (IBM, Armonk, New York, USA). Results
Between August 2003 and August 2013, 1317 patients underwent laparoscopic cholecystectomy and routine IOC. Sixteen patients (1⋅2 per cent) had stones in a non-dilated CBD. These patients did not undergo LCBDE and postoperative ERCP was performed. Some 215 patients (57 male; median age 65 (14–92) years) had a dilated CBD with CBD stones and underwent LCBDE; 94 of these were carried out as an emergency. Demographic details and presenting features are shown in Table 1. There was a significantly higher proportion of patients with obstructive jaundice and cholangitis in the emergency LCBDE group, whereas patients who underwent elective LCBDE mostly had biliary colic or acute
Operative technique Laparoscopic cholecystectomy was performed with a standard four-port technique using a 5-mm 30∘ laparoscope (Stryker, Kalamazoo, Michigan, USA). Routine transcystic intraoperative cholangiography (IOC) using X-rays was carried out in all patients undergoing laparoscopic cholecystectomy. Patients with filling defects and a CBD diameter greater than 8 mm underwent LCBDE via the transcholedochal route. A longitudinal supraduodenal choledochotomy was done using a Berci knife (Karl Storz, Tuttlingen, Germany) and microscissors. CBD stones were retrieved under vision using a flexible choledochoscope (Olympus, Tokyo, Japan) and a wire basket (Bard Medical, Murray Hill, New Jersey, USA). Following complete ductal clearance, which was confirmed via choledochoscopy, the CBD was closed with interrupted 3/0 Vicryl® sutures (Ethicon, Johnson & Johnson, Somerville, New Jersey, USA) in thin-walled ducts and continuous sutures in thick-walled ducts. A non-suction drain was left in the gallbladder bed, and was removed the following day if there was no bile leak. Laparoscopic ultrasonography and completion cholangiography were not performed.
Follow-up All patients were followed up in the outpatient clinic 6 weeks after surgery and reviewed afterwards if there were problems. No patient was lost to follow-up. © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
Demographic details of 215 patients who underwent laparoscopic common bile duct exploration
Table 1
Age (years)* Sex ratio (M : F) ASA grade I II III IV Preoperative LFTs* Bilirubin (μmol/l) ALP (units/l) Presentation Obstructive jaundice Cholangitis Acute pancreatitis Failed ERCP Acute cholecystitis with positive IOC Biliary colic with positive IOC Findings on IOC* CBD diameter (mm) No. of CBD stones
Elective (n = 121)
Emergency (n = 94)
70 (14–92) 30 : 91
61 (29–71) 27 : 67
19 (15⋅7) 83 (68⋅6) 17 (14⋅0) 2 (1⋅7)
26 (28) 52 (55) 12 (13) 4 (4)
17 (6–425) 140 (35–1171)
50 (6–513) 212 (45–1513)
15 (12⋅4) 0 (0) 13 (10⋅7) 7 (5⋅8) 22 (18⋅2)
30 (32) 15 (16) 5 (5) 3 (3) 36 (38)
64 (52⋅9)
5 (5)
10 (8–20) 2 (0–13)
12 (8–20) 1 (0–8)
P† 0⋅014‡ 0⋅492 0⋅076
< 0⋅001‡ 0⋅007‡ < 0⋅001
0⋅015‡ 0⋅369‡
Values in parentheses are percentages unless indicated otherwise; *values are median (range). ASA, American Society of Anesthesiologists; LFT, liver function test result; ALP, alkaline phosphatase; ERCP, endoscopic retrograde cholangiopancreatography; IOC, intraoperative cholangiography; CBD, common bile duct. †χ2 test, except ‡Mann–Whitney U test.
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45 40
Outcome of patients undergoing elective and emergency laparoscopic common bile duct exploration
Table 2
Elective Emergency
% of patients
35 30
Primary closure CBD clearance Conversion to open procedure Duration of surgery (min)* Morbidity Bile leak Bleeding Pneumonia Death Length of hospital stay (days)*
25 20 15 10 5 0 Normal LFTs Abnormal LFTs + USS + normal USS
USS with USS/MRCP with dilated CBD CBD stones
Results of baseline preoperative investigations in patients who had elective and emergency laparoscopic common bile duct (CBD) exploration. LFT, liver function test result; USS, abdominal ultrasound examination; MRCP, magnetic resonance cholangiopancreatography
Fig. 1
cholecystitis. The median time from admission to surgery in patients who underwent emergency LCBDE was 3 (1–7) days. Results of preoperative investigations are shown in Fig. 1. Outcomes following LCBDE are summarized in Table 2. The CBD was cleared successfully in 207 patients (96⋅3 per cent). Four patients (1⋅9 per cent) had no stones despite a dilated CBD with apparent filling defects (2 in each group). The procedure was converted to open surgery in 11 patients (5⋅1 per cent) because of adhesions/difficult anatomy (6) and impacted stones (5). Four of the patients with impacted stones required a choledochoduodenostomy owing to failure to retrieve the stones even following conversion. Four patients required ERCP after surgery to relieve the biliary obstruction. T tubes were inserted in 13 patients in the earlier part of the series, and the CBD was closed primarily in 198 patients. The overall morbidity rate was 6⋅0 per cent (13 patients). Seven patients had a persistent bile leak requiring reintervention (4 relaparoscopy, washout and resuturing of CBD; 3 ERCP). Postoperative bleeding occurred in three patients, and all required reoperation. Three patients developed pneumonia that settled with medical therapy. The overall mortality rate was 0⋅9 per cent (2 patients); both patients underwent emergency LCBDE. One was an 83-year-old woman who presented with cholangitis and developed severe pneumonia and multiple organ failure after operation. The other was a 90-year-old woman who presented with gallstone pancreatitis and died from ischaemic bowel. The overall median length © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
Elective (n = 121)
Emergency (n = 94)
112 (92⋅6) 117 (96⋅7) 5 (4⋅1) 99 (31–256) 8 (6⋅6) 4 (3⋅3) 2 (1⋅7) 2 (1⋅7) 0 (0) 3 (1–17)
86 (91) 90 (96) 6 (6) 103 (55–253) 5 (5) 3 (3) 1 (1) 1 (1) 2 (2) 3 (1–20)
P† 0⋅772‡ 0⋅557‡ 0⋅549 0⋅132§ 0⋅693 0⋅963 0⋅715 0⋅715 0⋅107 0⋅632§
Values in parentheses are percentages unless indicated otherwise; *values are median (range). CBD, common bile duct. †Fisher’s exact text, except ‡χ2 test and §Mann–Whitney U test.
of hospital stay was 3 days. There were no significant differences in outcomes between elective and emergency LCBDE. No patient was lost to follow-up at 6 weeks. Two patients developed recurrent choledocholithiasis 3 and 4 years after surgery that was cleared successfully at ERCP. One patient who underwent LCBDE with primary closure developed a mid-CBD stricture 3 months after operation, which required two sessions of endoscopic balloon dilatation; the patient remained symptom-free at 3 years of follow-up.
Discussion
The principal findings of this study were that LCBDE via the transcholedochal route can achieve successful CBD clearance rates in over 95 per cent of patients with low morbidity and mortality rates, and a median length of hospital stay of 3 days. Primary closure seems feasible and safe after both elective and emergency LCBDE. Emergency LCBDE can be performed in a timely manner with efficacy and morbidity equivalent to that of an elective procedure. These outcomes compare favourably with results from randomized trials2,5 and large case series9 – 13 . A strength of this study is that it is one of the largest series of LCBDE procedures via the transcholedochal route, with over 40 per cent as an emergency procedure. Most series10 – 12,14,15 reported the results of LCBDE in smaller cohorts; the largest published series9 in the UK of transcholedochal exploration and primary closure included 120 patients, and reported a clearance rate of 96⋅7 per cent, morbidity rate of 8⋅3 per cent and length of hospital stay of 2⋅1 days. However, over 90 per cent of the procedures were performed in the elective setting and only ten patients www.bjs.co.uk
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D. S. Y. Chan, P. A. Jain, A. Khalifa, R. Hughes and A. L. Baker
underwent emergency LCBDE. None of the 16 randomized trials analysed in the Cochrane review4 comparing surgical versus endoscopic treatment of CBD stones included more than 150 patients in the LCBDE arm. This study has also several potential limitations. This was a retrospective observational study and so open to selection bias. This was minimized by analysing a consecutive series of patients who had undergone LCBDE by a single surgeon. Patients undergoing emergency LCBDE were younger as surgery was more likely to be offered to younger patients with less co-morbidity during the index admission. Although follow-up was complete in all patients at 6 weeks after surgery, it was not the authors’ routine practice to continue long-term outpatient follow-up for individuals who had recovered well and were asymptomatic. The extremely low incidence of delayed complications after LCBDE does not justify routine long-term follow-up6 . Patients who developed problems such as recurrent calculi or strictures were referred for further endoscopic treatment and, as far as the authors are aware, only one patient developed a stricture and two developed recurrent calculi. T tubes were inserted only in the earlier part of the series and primary closure of the choledochotomy was adopted as the evidence for this technique increased8,13,16 . The transcystic route has been championed as the first-line treatment for CBD stones as it avoids a choledochotomy and recovery is similar to that among patients undergoing laparoscopic cholecystectomy alone7 . However, owing to the restrictions of the transcystic route (patent, wide, straight cystic duct with stones less than 5 mm in diameter) and the low success rates of this approach of under 60 per cent7,17 , the authors prefer routine use of the transcholedochal route. Some groups have advocated a transverse choledochotomy as it may be technically easier to perform and close, and less likely to result in strictures9 . The incidence of bile duct strictures following choledochotomy appears to be low, regardless of whether it is performed transversely or longitudinally. No biliary strictures were reported in case series of 10011 and 13713 patients when transverse or longitudinal choledochotomies respectively were performed. However, one patient (0⋅8 per cent) in a series of 120 developed a mid-duct stricture following a transverse choledochotomy9 . In the present series, only one patient (0⋅5 per cent) developed a biliary stricture 3 months after surgery. There is insufficient evidence to support one approach over the other. Bile leaks occurred in seven patients (3⋅3 per cent), and were treated by relaparoscopy for washout and resuturing of the CBD, or by ERCP. Not surprisingly, there was a significantly higher proportion of patients with obstructive jaundice and cholangitis
in the emergency LCBDE group. Surgery was offered to these patients during the index emergency admission and LCBDE performed on the next available inpatient operating list to prevent further readmissions; this could ultimately lead to cost savings. The limited provision of ERCP compared with the demand was an important factor that led the authors to offer one-stage surgery during the index admission. As the evidence supporting LCBDE and primary suture increases, patients with choledocholithiasis will expect to be offered this single-stage approach. LCBDE is a technically demanding procedure with a long learning curve and should be performed by skilled surgeons or under close supervision with appropriate training18 .
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Disclosure
The authors declare no conflict of interest. References 1 Williams EJ, Green J, Beckingham I, Parks R, Martin D, Lombard M; British Society of Gastroenterology. Guidelines on the management of common bile duct stones (CBDS). Gut 2008; 57: 1004–1021. 2 Koc B, Karahan S, Adas G, Tutal F, Guven H, Ozsoy A. 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: 457–463. 3 Scientific Committee of the European Association for Endoscopic Surgery (E.A.E.S.). Diagnosis and treatment of common bile duct stones (CBDS). Results of a consensus development conference. Surg Endosc 1998; 12: 856–864. 4 Dasari BV, Tan CJ, Gurusamy KS, Martin DJ, Kirk G, McKie L et al. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev 2013; (12)CD003327. 5 Rogers SJ, Cello JP, Horn JK, Siperstein AE, Schecter WP, Campbell AR et al. Prospective randomized trial of LC + LCBDE vs ERCP/S + LC for common bile duct stone disease. Arch Surg 2010; 145: 28–33. 6 Bansal VK, Misra MC, Rajan K, Kilambi R, Kumar S, Krishna A 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 2014; 28: 875–885. 7 Hanif F, Ahmed Z, Samie MA, Nassar AH. Laparoscopic transcystic bile duct exploration: the treatment of first choice for common bile duct stones. Surg Endosc 2010; 24: 1552–1556.
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8 Gurusamy KS, Koti R, Davidson BR. T-tube drainage versus primary closure after laparoscopic common bile duct exploration. Cochrane Database Syst Rev 2013; (6)CD005641. 9 Khaled YS, Malde DJ, de Souza C, Kalia A, Ammori BJ. Laparoscopic bile duct exploration via choledochotomy followed by primary duct closure is feasible and safe for the treatment of choledocholithiasis. Surg Endosc 2013; 27: 4164–4170. 10 Savita KS, Bhartia VK. Laparoscopic CBD Exploration. Indian J Surg 2010; 72: 395–399. 11 Decker G, Borie F, Millat B, Berthou J, Deleuze A, Drouard F et al. One hundred laparoscopic choledochotomies with primary closure of the common bile duct. Surg Endosc 2003; 17: 12–18. 12 Thompson MH, Tranter SE. All-comers policy for laparoscopic exploration of the common bile duct. Br J Surg 2002; 89: 1608–1612. 13 Cai H, Sun D, Sun Y, Bai J, Zhao H, Miao Y. Primary closure following laparoscopic common bile duct exploration combined with intraoperative cholangiography and choledochoscopy. World J Surg 2012; 36: 164–170.
14 Lee HM, Min SK, Lee HK. Long-term results of laparoscopic common bile duct exploration by choledochotomy for choledocholithiasis: 15-year experience from a single center. Ann Surg Treat Res 2014; 86: 1–6. 15 Rojas-Ortega S, Arizpe-Bravo D, Marín López ER, Cesin-Sánchez R, Roman GR, Gomez C. Transcystic common bile duct exploration in the management of patients with choledocholithiasis. J Gastrointest Surg 2003; 7: 492–496. 16 Yin Z, Xu K, Sun J, Zhang J, Xiao Z, Wang J 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: 54–66. 17 Gigot JF, Navez B, Etienne J, Cambier E, Jadoul P, Guiot P. A stratified intraoperative surgical strategy is mandatory during laparoscopic common bile duct exploration for common bile duct stones. Surg Endosc 1997; 11: 722–728. 18 Tutton MG, Pawa N, Arulampalam TH, Motson RW. Training higher surgical trainees in laparoscopic common bile duct exploration. World J Surg 2010; 34: 569–573.
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