Abstract
Background
Laparoscopic CBD exploration (LCBDE) is an accepted treatment modality for single stage management of CBD stones in fit patients. A transcholedochal approach is preferred in patients with a dilated CBD and large impacted stones in whom ductal clearance remains problematic. There are very few studies comparing intraoperative cholangiography (IOC) with choledochoscopy to determine ductal clearance in patients undergoing transcholedochal LCBDE. This series represents the first of those comparing the two from Asia.
Methods
Between April 2009 and October 2012, 150 consecutive patients with CBD stones were enrolled in a prospective randomized study to undergo transcholedochal LCBDE on an intent-to-treat basis. Patients with CBD diameter of less than 9 mm on preoperative imaging were excluded from the study. Out of the 132 eligible patients, 65 patients underwent IOC (Group A), and 67 patients underwent intraoperative choledochoscopy (Group B) to determine CBD clearance.
Results
There were no differences between the two groups in the demographic profile and the preoperative biochemical findings. There was no conversion to open procedures, and complete stone clearance was achieved in all the 132 cases. The mean CBD diameter and the mean number of CBD stones removed were comparable between the two groups. Mean operating time was 170 min in Group A and 140 min in Group B (p < 0.001). There was no difference in complications between the two groups. Nine patients in Group A (13.8 %) showed non-passage of contrast into the duodenum on IOC which resolved after administration of i.v. glucagon, suggesting a transient spasm of sphincter of Oddi. Two patients (3 %) showed a false-positive result on IOC which had to be resolved with choledochoscopy.
Conclusions
The present study showed that intraoperative choledochoscopy is better than IOC for determining ductal clearance after transcholedochal LCBDE and is less cumbersome and less time-consuming.
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References
Cuschieri A, Lezoche E, Morino M, Croce E, Lacy A, Toouli J, Faggioni A, Ribeiro VM, Jakimowicz J, Visa J, Hanna GB (1999) E.A.E.S. multicenter prospective randomized trial comparing two-stage vs single-stage management of patients with gallstone disease and ductal calculi. Surg Endosc 13:952–957
Clayton ES, Connor S, Alexakis N, Leandros E (2006) Meta-analysis of endoscopy and surgery versus surgery alone for common bile duct stones with the gallbladder in situ. Br J Surg 93:1185–1191
Martin DJ, Vernon DR, Toouli J (2006) Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev 19:CD003327
Costi R, Mazzeo A, Tartamella F, Manceau C, Vacher B, Valverde A (2010) Cholecystocholedocholithiasis: a case–control study comparing the short- and long-term outcomes for a “laparoscopy first” attitude with the outcome for sequential treatment (systematic endoscopic sphincterotomy followed by laparoscopic cholecystectomy). Surg Endosc 24:51–62
Del Santo P, Kazarian KK, Rogers JF, Bevois PA, Hall JR (1985) Prediction of operative cholangiography in patients undergoing elective cholecystectomy with routine liver function chemistries. Surgery 98:7–11
Pernthaler H, Sandbichler P, Schmid T, Margreiter R (1990) Operative cholangiography in elective cholecystectomy. Br J Surg 77:399–400
Stuart SA, Simpson TI, Alvord LA, Williams MD (1998) Routine intraoperative laparoscopic cholangiography. Am J Surg 176:632–637
Carroll BJ, Phillips EH, Daykhovsky L, Grundfest WS, Gershman A, Fallas M, Chandra M (1992) Laparoscopic choledochoscopy: an effective approach to the common duct. J Laparoendosc Surg 2:15–21
Berci G, Shore L, Morgenstern M, Hamlin A (1978) Choledochoscopy and operative fluorocholangiography in the prevention of retained bile duct stones. World J Surg 2:411–427
Phillips EH, Carroll Pearlstein BJ, Pearlstein AR, Daykhovsky L, Fallas MJ (1993) Laparoscopic choledochoscopy and extraction of common bile duct stones. World J Surg 17:22–28
Topal B, Aerts R, Penninckx F (2007) Laparoscopic common bile duct stone clearance with flexible choledochoscopy. Surg Endosc 21:2317–2321
Chander J, Vindal A, Lal P, Gupta N, Ramteke VK (2011) Laparoscopic management of CBD stones:an Indian experience. Surg Endosc 25:172–181
Tang CN, Tsui KK, Ha JP, Siu WT, Li MK (2006) Laparoscopic exploration of the common bile duct: 10-year experience of 174 patients from a single centre. Hong Kong Med J 12:191–196
Rosseland AR, Glomsaker TB (2000) Asymptomatic common bile duct stones. Eur J Gastroenterol Hepatol 12:1171–1173
Petelin JB (2003) Laparoscopic common bile duct exploration. Surg Endosc 17:1705–1715
Fletcher DR (1994) Changes in the practice of biliary surgery and ERCP during the introduction of laparoscopic cholecystectomy to Australia: their possible significance. Aust N Z J Surg 64:75–80
NIH Consens State Sci Statements (2002) NIH state-of-the-science statement on endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and therapy. 19(1):1–26
Christensen M, Matzen P, Schulze S, Rosenberg J (2004) Complications of ERCP: a prospective study. Gastrointest Endosc 60:721–731
Moreaux J (1995) Traditional surgical management of common bile duct stones: a prospective study during a 20-year experience. Am J Surg 169:220–226
Sheridan WG, Williams HO, Lewis MH (1987) Morbidity and mortality of common bile duct exploration. Br J Surg 74:1095–1099
Crawford DL, Phillips EH (1999) Laparoscopic common bile duct exploration. World J Surg 23:343–349
Bagnato VJ (1993) Laparoscopic choledochoscopy and choledocholithotomy. Surg Laparosc Endosc 3:164–166
Philips EH (1994) Controversies in the management of common duct calculi. Surg Clin North Am 74:931–948 discussion 949-951
Paganini AM, Feliciotti F, Guerrieri M, Tamburini A, De Sanctis A, Campagnacci R, Lezoche E (2001) Laparoscopic common bile duct exploration. J Laparoendosc Adv Surg Tech A 11:391–400
Berci G, Morgenstern L (1994) Laparoscopic management of common bile duct stones. A multi-institutional SAGES study. Society of American Gastrointestinal Endoscopic Surgeons. Surg Endosc 8:1168–1174 discussion 1174-1175
Waage A, Strömberg C, Leijonmarck CE, Arvidsson D (2003) Long-term results from laparoscopic common bile duct exploration. Surg Endosc 17:1181–1185
Millat B, Fingerhut A, Deleuze A, Briandet H, Marrel E, de Seguin C, Soulier P (1995) Prospective evaluation in 121 consecutive unselected patients undergoing laparoscopic treatment of choledocholithiasis. Br J Surg 82:1266–1269
Isla AM, Griniatsos J, Wan A (2002) A technique for safe placement of a biliary endoprosthesis after laparoscopic choledochotomy. J Laparoendosc Adv Surg Tech A 12:207–211
Decker G, Borie F, Millat B, Berthou JC, Deleuze A, Drouard F, Guillon F, Rodier JG, Fingerhut A (2003) One hundred laparoscopic choledochotomies with primary closure of the common bile duct. Surg Endosc 17:12–18
Berthou JCh, Dron B, Charbonneau P, Moussalier K, Pellissier L (2007) Evaluation of laparoscopic treatment of common bile duct stones in a prospective series of 505 patients: indications and results. Surg Endosc 21:1970–1974
Rhodes M, Nathanson L, O’Rourke N, Fielding G (1995) Laparoscopic exploration of the common bile duct: lessons learned from 129 consecutive cases. Br J Surg 82:666–668
Ha JP, Tang CN, Siu WT, Chau CH, Li MK (2004) Primary closure versus T-tube drainage after laparoscopic choledochotomy for common bile duct stones. Hepatogastroenterology 51:1605–1608
Arvidsson D, Berggren U, Haglund U (1998) Laparoscopic common bile duct exploration. Eur J Surg 164:369–375
Teh CH, Chew SP, Teoh TA, Chua CL (1997) Use of a biliary stent in laparoscopic choledochotomy for removal of duct stones. Br J Surg 84:1233–1234
Paganini AM, Guerrieri M, Sarnari J, De Sanctis A, D’Ambrosio G, Lezoche G, Perretta S, Lezoche E (2007) Thirteen years’ experience with laparoscopic transcystic common bile duct exploration for stones. Effectiveness and long-term results. Surg Endosc 21:34–40
Lee HK, Han HS, Lee JH, Min SK (2005) Nontraumatic perforation of the bile duct treated with laparoscopic surgery. J Laparoendosc Adv Surg Tech A 15:329–332
Pace BW, Cosgrove J, Breuer B, Margolis IB (1992) Intraoperative cholangiography revisited. Arch Surg 127:448–450
Hauer-Jensen M, Kåresen R, Nygaard K, Solheim K, Amlie E, Havig O, Viddal KO (1986) Consequences of routine peroperative cholangiography during cholecystectomy for gallstone disease: a prospective, randomized study. World J Surg 10:996–1002
Soper NJ, Dunnegan DL (1992) Routine versus selective intra-operative cholangiography during laparoscopic cholecystectomy. World J Surg 16:1133–1140
Kharbutli B, Velanovich V (2008) Management of preoperatively suspected choledocholithiasis: a decision analysis. J Gastrointest Surg 12:1973–1980
Hamouda AH, Goh W, Mahmud S, Khan M, Nassar AH (2007) Intraoperative cholangiography facilitates simple transcystic clearance of ductal stones in units without expertise for laparoscopic bile duct surgery. Surg Endosc 21:955–959
Griniatsos J, Karvounis E, Isla AM (2005) Limitations of fluoroscopic intraoperative cholangiography in cases suggestive of choledocholithiasis. J Laparoendosc Adv Surg Tech A 15:312–317
Phillips EH, Berci G, Carroll B, Daykhovsky L, Sackier J, Paz-Partlow M (1990) The importance of intraoperative cholangiography during laparoscopic cholecystectomy. Am Surg 56:792–795
Fiore NF, Ledniczky G, Wiebke EA, Broadie TA, Pruitt AL, Goulet RJ, Grosfelf JL, Canal DF (1997) An analysis of perioperative cholangiography in one thousand laparoscopic cholecystectomies. Surgery discussion 821-823:817–821 discussion 821–823
Trias M, Targarona EM, Ros E, Bordas JM, Perez Ayuso RM, Balagué C, Pros I, Teres J (1997) Prospective evaluation of a minimally invasive approach for treatment of bile-duct calculi in the high-risk patient. Surg Endosc 11:632–635
Carlei F, Lezoche E, Lomanto D, Schietroma M, Paganini A, Sottili M, Nardovino M (1997) Cholecystoenteric fistula is not a contraindication for laparoscopic cholecystectomy: report of five cases treated by laparoscopic approach. Surg Laparosc Endosc 7:403–406
Thompson MH, Tranter SE (2002) All-comers policy for laparoscopic exploration of the common bile duct. Br J Surg 89:1608–1612
Shuchleib S, Chousleb A, Mondragon A, Torices E, Licona A, Cervantes J (1999) Laparoscopic common bile duct exploration. World J Surg 23:698–701 discussion 702
Lacitignola S, Minardi M (2008) Management of common bile duct stones: a ten-year experience at a tertiary care center. JSLS 12:62–65
Riciardi R, Islam S, Canete JJ, Arcand PL, Stoker ME (2003) Effectiveness and long-term results of laparoscopic common bile duct exploration. Surg Endosc 17:19–22
Shojaiefard A, Esmaeilzadeh M, Ghafouri A, Mehrabi A (2009) Various techniques for the surgical treatment of common bile duct stones: a meta review. Gastroenterol Res Pract 2009:840208. doi:10.1155/2009/840208
Li MK, Tang CN, Lai EC (2011) Managing concomitant gallbladder stones and common bile duct stones in the laparoscopic era: a systematic review. Asian J Endosc Surg 4:53–58
Abdel-Raouf A (2009) Laparoscopic choledochotomy. Egypt J Surg 28:62–66
Martin IJ, Bailey IS, Rhodes M, O’Rourke N, Nathanson L, Fielding G (1998) Towards T-tube free laparoscopic bile duct exploration: a methodologic evolution during 300 consecutive procedures. Ann Surg 228:29–34
Kim EK, Lee SK (2004) Laparoscopic treatment of choledocholithiasis using modified biliary stents. Surg Endosc 18:303–306
Robinson G, Hollinshead J, Falk G, Moulton J (1995) Technique and results of laparoscopic choledochotomy for the management of bile duct calculi. Aust N Z J Surg 65:347–349
Lezoche E, Paganini AM, Carlei F, Feliciotti F, Lomanto D, Guerrieri M (1996) Laparoscopic treatment of gallbladder and common bile duct stones: a prospective study. World J Surg 20:535–541 discussion 542
Jones DB, Dunnegan DL, Soper NJ (1995) Results of a change to routine fluorocholangiography during laparoscopic cholecystectomy. Surgery 118:693–701 discussion 701-702
Kullman E, Borch K, Lindström E, Svanvik J, Anderberg B (1996) Management of bile duct stones in the era of laparoscopic cholecystectomy: appraisal of routine operative cholangiography and endoscopic treatment. Eur J Surg 162:873–880
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Anubhav Vindal, Jagdish Chander, Pawanindra Lal, and Balu Mahendra have no conflicts of interest and no disclosures to make.
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Vindal, A., Chander, J., Lal, P. et al. Comparison between intraoperative cholangiography and choledochoscopy for ductal clearance in laparoscopic CBD exploration: a prospective randomized study. Surg Endosc 29, 1030–1038 (2015). https://doi.org/10.1007/s00464-014-3766-5
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DOI: https://doi.org/10.1007/s00464-014-3766-5