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Management of CBD stone during laparoscopic cholecystectomy

Management of CBD stone during laparoscopic cholecystectomy. Dr Wong Tak Man Mandy Kwong Wah Hospital. The incidence of choledocholithiasis in patients undergoing cholecystectomy varies with age, ranging from 6% in patients less than 80 years old to 33% in patients more than 80 years old.

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Management of CBD stone during laparoscopic cholecystectomy

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  1. Management of CBD stone during laparoscopic cholecystectomy Dr Wong Tak Man Mandy Kwong Wah Hospital

  2. The incidence of choledocholithiasis in patients undergoing cholecystectomy varies with age, ranging from 6% in patients less than 80 years old to 33% in patients more than 80 years old. Johnson AG, Hosking SW. Appraisal of the management of bile duct stones. Br J Surg 1987;74:555–560. • Approximately 10% of patients who undergo laparoscopic cholecystectomy harbor common bile duct stones Way LW, Admirand WJ, Dunphy JE (1972) Management of choledocholithiasis. Ann Surg 176: 347–359

  3. It is estimated that 5% to 12% of patients with choledocholithiasis may be completely asymptomatic and have normal liver function tests. Acosta MJ. The usefulness of stool screening for diagnosing cholelithiasis in acute pancreatitis. A description of the technique. Am J Dig Dis 1977;22:168–172.

  4. 2-step approach: • Lap cholecystectomy, then post-cholecystectomy ERCP • 1-step approach: • Lap cholecystectomy and lap CBD exploration • Lap cholecystectomy and intra-operative ERCP • Open cholecystectomy and CBD exploration

  5. 2-step approach: • Lap cholecystectomy, then post-cholecystectomy ERCP • 1-step approach: • Lap cholecystectomy and lap CBD exploration • Lap cholecystectomy and intra-operative ERCP • Open cholecystectomy and CBD exploration

  6. Post-cholecystectomy ERCP(2-stage approach) • Failure rate: 2-4% • Need further endoscopic procedure or re-operation Huntington TR. Laparoscopic biliary guide wire: a simplified approach to choledocholithiasis. Gastrointest Endosc 1997;45:295-7.

  7. Transcystic biliary stenting • Insert a biliary stent through the cystic duct into the CBD and through the sphincter of Oddi. • Ensures access to the bile duct for postoperative endoscopic sphincterotomy. • Increase the success rate of post-operative ERCP

  8. 2-step approach: • Lap cholecystectomy, then post-cholecystectomy ERCP • 1-step approach: • Lap cholecystectomy and lap CBD exploration • Transcystic approach • Transcholedocal approach • Lap cholecystectomy and intra-operative ERCP • Open cholecystectomy and CBD exploration

  9. Lap CBD Exploration

  10. Methods for stone retrieval: • Irrigation • Balloon manipulation (Fogarty catheter) • Basket maneuver • Choledochoscopy • Electrohydraulic lithotripsy • Completion cholangiogram to confirm ductal clearance, or to decide for open conversion in case of retained stones

  11. LCBDE (transcystic approach) • Gallbladder is retracted toward right hemidiaphragm with forceps inserted through the most lateral port. • Cystic duct is dilated, if necessary, either with over-the-wire mechanical dilator or over-the-wire pneumatic dilator. • Choledochoscope is inserted through midclavicular port into cystic duct and guided into CBD with atraumatic forceps inserted through medial epigastric port.

  12. Advantage: • Less invasive • Minimal morbidity, no T-tube, no drain, and a rapid return to normal activity in most cases • Disadvantage: • Limited by cystic duct diameter • Depends on the stone that need to be removed

  13. Indications: • filling defects at cholangiography • Stones smaller than 10mm • fewer than 9 stones • Contraindications: • stones larger than 1 cm • stones proximal to the cystic duct entrance into the CBD • small friable cystic duct, <3mm in diameter • tortuous cystic duct • 10 or more stones

  14. Applicable in more than 85% of cases • Success rate of 85% to 95% • More cost effective than postoperative endoscopic retrograde cholangiopancreatography (ERCP) S. Lyass. Laparoscopic transcystic duct common bile duct exploration. Surg Endosc (2006) 20: S441–S445

  15. LCBDE (transcholedocal approach) • Longitudinal incision at supraduodenal CBD • Limited to 1 cm or diameter of the largest stone • Choledochoscope is inserted through mid-clavicular port and guided into CBD with atraumatic forceps inserted through medial epigastric port • No stay suture is required

  16. Advantage: • Useful in cases when transcystic method is not feasible, such as large stones, intrahepatic stones, or a miniscule or tortuous cystic duct • Disadvantage: • Technically demanding • Require suturing and knot-tying skills not necessary in the transcystic method • Limited by CBD diameter • Increased risk of post-operative bile leakage and late stenosis

  17. J. B. Petelin. Laparoscopic common bile duct exploration. Lessons learned from >12 years’ experience. Surg Endosc (2003) 17: 1705–1715

  18. Transcystic or transcholedochal? Which method should we choose?

  19. Factors influencing duct exploration approach: +, positive or neutral effect. -, negative effect

  20. 2-step approach: • Lap cholecystectomy, then post-cholecystectomy ERCP • 1-step approach: • Lap cholecystectomy and lap CBD exploration • Lap cholecystectomy and intra-operative ERCP • Rendezvous technique (transcystic guide wire) • Open cholecystectomy and CBD exploration

  21. Intra-operative ERCP • Endoscopic sphincterotomy

  22. Advantage: • Allows immediate conversion under the same anaesthesia to open surgery if ERCP fails. • Disadvantage: • Difficult due to supine position • Difficult cannulation • Injection of contrast into pancreatic duct • Post-ERCP pancreatitis • Require collaboration of 2 teams – surgeon, endoscopist +/- radiologist.

  23. Rendezvous technique: • After intra-operative cholangiogram, a transcystic guide wire in inserted through a small incision at cystic duct, advanced into duodenum through papilla • The tip of the guide wire is viewed using endoscope, and pulled out of patient’s mouth by a polypectomy snare • A traditional sphincterotome is introduced along the guide wire that allow direct cannulation of papilla and sphincterotomy • Stone extraction can also be performed using the guidance of the wire

  24. Saccomani G. Combined endoscopic treatment for cholelithiasis associated with choledocholithiasis. Surg Endosc. 2005;19 (7):910-914.

  25. Advantage: • Easy cannulation of CBD • Avoid contrast injection into pancreatic duct

  26. Rendezvous technique (case series): • Success rate: 95% • Failure due to difficulty in passing guide wire through the papilla • CBD stone clearance can still be achieved with traditional sphincterotomy • Complication rate: 3.7% • post-sphincterotomy bleeding (2) • post-sphincterotomy perforation (2) • death due to post-ERCP pancreatitis (1) Giuseppe Borzellino. Treatment for Retrieved Common Bile Duct Stones During Laparoscopic Cholecystectomy. The Rendezvous Technique. ARCH SURG/VOL 145 (NO. 12), DEC 2010

  27. Comparing different approach

  28. Lap CBDE vs post-op ERCP

  29. Nathanson 2005 , randomized trial Nathanson LK. Postoperative ERCP versus laparoscopic choledochotomy for clearance of selected bile duct calculi: a randomized trial. Ann Surg. 2005;242(2):188-192.

  30. Edward H. Phillips. Treatment of Common Bile Duct Stones Discovered during Cholecystectomy. J Gastrointest Surg (2008) 12:624–628

  31. The re-operation rate for LCBDE is comparable to post-op ERCP Berci G, Morgenstern L. Laparoscopic management of common bile duct stones: a multi-institutional SAGES study. Society of American Gastrointestinal Endoscopic Surgeons. Surg Endosc. 1994;8:1168–1174.

  32. CBD less than 7 mm • Severely inflammed friable tissue •  for post-op ERCP • Patient with Billroth II gastrectomy • Failed ERCP access • Long delay to transfer patient to other locations for ERCP •  for LCBDE Nathanson LK. Postoperative ERCP versus laparoscopic choledochotomy for clearance of selected bile duct calculi: a randomized trial. Ann Surg. 2005;242(2):188-192.

  33. Intra-op ERCP vs post-op ERCP

  34. Rendezvous technique: • High success rate in clearing ductal stones (94%) • Less complications (especially pancreatitis) • Mean hospital stay is similar to simple lap cholecystecyomy • Although operating room time of combined method is longer than simple lap cholecystectomy Iodice G. Single-step treatment of gallbladder and bile duct stones: a combined endoscopic-laparoscopic technique. Gastrointest Endosc. 2001;53(3):336-338.

  35. Rabago LR. Two-stage treatment with preoperative endoscopic retrograde cholangiopancreatography (ERCP) compared with single stage treatment with intraoperative ERCP for patients with symptomatic cholelithiasis with possible choledocholithiasis. Endoscopy. 2006;38(8):779-786. Morino M. Preoperative endoscopic sphincterotomy versus laparoendoscopic rendezvous in patients with gallbladder and bile duct stones. Ann Surg. 2006;244(6):889-896.

  36. Intra-operative ERCP (Rendezvous technique) has high success rate of CBD clearance, and less post-ERCP pancreatitis when compared to the 2-stage method.

  37. LCBDE vs intra-op ERCP

  38. Prospective study No difference in terms of surgical time, number of extracted stones, retained CBD stones, hospital charges and post-operative hospital stay. Hong DF. Comparison of laparoscopic cholecystectomy combined with intraoperative endoscopic sphincterotomy and laparoscopic exploration of the common bile duct for cholecystocholedocholithiasis. Surg Endosc. 2006;20(3):424-427.

  39. Systemic review Tranter SE, Thompson MH (2002) Comparison of endoscopic sphincterotomy and laparoscopic exploration of the common bile duct. Br J Surg 89: 1495–1504

  40. Both LCBDE and LC + intra-op ERCP are safe and effective • Stones larger than 20 mm are not suitable for stone removal by endoscopic sphincterotomy • Excessive cutting of sphincter may increase complications Hong DF. Comparison of laparoscopic cholecystectomy combined with intraoperative endoscopic sphincterotomy and laparoscopic exploration of the common bile duct for cholecystocholedocholithiasis. Surg Endosc. 2006;20(3):424-427.

  41. 2-step approach: • Lap cholecystectomy, then post-cholecystectomy ERCP • 1-step approach: • Lap cholecystectomy and lap CBD exploration • Lap cholecystectomy and intra-operative ERCP • Open cholecystectomy and CBD exploration

  42. Open CBD exploration • Open CBDE remains the “gold standard” for selected, rare patients such as those with Mirizzi syndrome, Billroth II anatomy, and those requiring a drainage procedure. • Morbidity from 11% to 14% • Mortality from 0.6% to 1%. • Morgenstern L, Wong L, Berci G. Twelve hundred open cholecystectomies before the laparoscopic era. A standard for comparison. Arch Surg 1992;127:400–403.

  43. 2-step approach: • Lap cholecystectomy, then post-cholecystectomy ERCP • Transcystic biliary stenting • 1-step approach: • Lap cholecystectomy and lap CBD exploration • Transcystic approach • Transcholedocal approach • Lap cholecystectomy and intra-operative ERCP • Rendezvous technique • Open cholecystectomy and CBD exploration

  44. Edward H. Phillips. Treatment of Common Bile Duct Stones Discovered during Cholecystectomy. J Gastrointest Surg (2008) 12:624–628

  45. However, it is unrealistic to extrapolate standards of care based on the available RCTs given the wide variation in skills and resources available in different communities. • Individual surgeons must recognize their own limitations and the limitations of available endoscopists and perform the safest approach.

  46. Conclusion • Lap CBD exploration is comparable to post-op ERCP in terms of ductal clearance, morbidity and re-operation rate. • Lap CBD exploration is comparable to intra-operative ERCP in terms of success rate, stone clearance and complications. • Intra-operative ERCP has higher success rate and less complications (esp. pancreatitis) when compared to post-op ERCP

  47. Decision depends on: • Stone number and size • Cystic duct size and anatomy • CBD size • Severity of tissue inflammation • Past surgical history • Surgeon’s experience

  48. THANK YOU!

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