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

Abstract

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.

Laparoscopic transcystic bile duct exploration: the treatment of first choice for common bile duct stones

“…There is a predictably small increase in the overall intraoperative time (mean, 25 min; Table 2). The success of TCE described in the current literature varies from 63% to 95%, and was 55% in our study [18,19]. This relatively lower TCE rate was thought to be mainly due to a majority of our patient population (84%) having large stones (mean size 10 ± 4 mm) in their bile ducts and due to the lack of an ultrasound lithotripter in our setup.…”

Minimally invasive treatment of cholecysto-choledocal lithiasis: The point of view of the surgical endoscopist

“…In a setting where all facilities are available, decision in the selection of the therapeutic option depends on the patients, the number and size of CBD stones, the anatomy of the cystic duct and common bile duct, the surgical history of patients and local expertise. tic duct anatomy (tortuous, < 3 mm in diameter), proximal (hepatic duct) stones, strictures and large (> 6 mm) or numerous stones (> 5) [43][44][45] . Following laparoscopic choledochotomy, closure over a T-tube may be required if the common bile duct is inflamed [46][47][48] .…”

“…ERCP training program is mandatory to achieve selective cannulation rates in excess of 80%. It is important that once formal training is completed endoscopists perform an adequate number of biliary sphincterotomies (40)(41)(42)(43)(44)(45)(46)(47)(48)(49)(50) per year to maintain their performance. It is recommended that all endoscopists performing ERCP should be able to supplement standard stone extraction techniques with advanced techniques (mechanical lithotripsy, electro-hydraulic lithotripsy and laser lithotripsy) when required [52][53][54][55][56][57] .…”

Why is there recurrence after transcystic laparoscopic bile duct clearance? Risk factor analysis

“…The importance of the number of stones was mainly reported as a cause of failure [25], but we believe it could be a useful parameter in the follow-up process of these patients, also because the transcystic technique is applied in those cases in which the diameter of the stones is below 5 mm with the possibility of there being microcalculi which the cholangiographic control cannot detect.…”