Surgical (Open and laparoscopic) management of large difficult CBD stones after different sessions of endoscopic failure: A retrospective cohort study

Abstract

Objectives For complicated common bile duct stones (CBDS) that cannot be extracted by endoscopic retrograde cholangiopancreatography (ERCP), management can be safely by open or laparoscopic CBD exploration (CBDE). The study aimed to assess these surgical procedures after endoscopic failure. Methods We analyzed 85 patients underwent surgical management of difficult CBDS after ERCP failure, in the period from 2013 to 2018. Results Sixty-seven (78.8%) and 18(21.2%) of our patients underwent single and multiple ERCP sessions respectively. An impacted large stone was the most frequent cause of ERCP failure (60%). Laparoscopic CBDE(LCBDE), open CBDE(OCBDE) and the converted cases were 24.7% (n = 21), 70.6% (n = 60), and 4.7% (n = 4) respectively. Stone clearance rate post LCBDE and OCBDE reached 95.2% and 95% respectively, Eleven (12.9%) of our patients had postoperative complications without mortality. By comparing LCBDE and OCBDE; there was a significant association between the former and longer operative time. On comparing, T-tube and 1ry CBD closure in both OCBDE and LCBDE, there was significantly longer operative time, and post-operative hospital stays in the former. Furthermore, in OCBDE group, choledocoscopy had an independent direction to 1ry CBD repair and significant association with higher stone clearance rate, shorter operative time, and post-operative hospital stay. Conclusion Large difficult CBDS can be managed either by open surgery or laparoscopically with acceptable comparable outcomes with no need for multiple ERCP sessions due to their related morbidities; furthermore, Open choledocoscopy has a good impact on stone clearance rate with direction towards doing primary repair that is better than T-tube regarding operative time and post-operative hospital stay.

Laparoscopic common bile duct exploration in patients with previous abdominal biliary tract operations

“…In addition, ERCP can sometimes cause serious ERCP-related complications, such as bleeding, duodenal perforation, cholangitis, and pancreatitis. Moreover, it may be difficult or impossible to clear large, multiple, intrahepatic ducts or impacted stones in the CBD by ERCP, and patients with these symptoms can benefit from open CBD exploration (OCBDE) or LCBDE, as these procedures have a high success rate in salvaging such stones [4]. In addition, it has been reported that endoscopic sphincterotomy (EST) may cause duodenobiliary, pancreatic juice and intestinal content reflux that results in recurrent bile duct stone formation, cholecystitis, inflammation in the bile duct, and cholangiocarcinoma [5].…”

Percutaneous Transhepatic Flexible Ureteroscope-Guided Frequency-Doubled Dual Pulse ND:YAG Laser Lithotripsy for Refractory Choledocholithiasis

“…Large di cult CBDS also can be managed either by open surgery or laparoscopically with comparable and acceptable outcomes and without the need for multiple ERCP sessions due to their related morbidities. 35 Open choledocoscopy was considered to be more suitable for stone clearance than a T-tube. 36 For concurrent gallbladder and CBD stones, Liu et al introduced a novel technique, which they referred to as sequential percutaneous transhepatic balloon dilation (PTBD) and percutaneous transhepatic extraction and balloon dilation (PTEBD).…”

Outcomes of laparoscopic common bile duct exploration (LCBDE) after failed endoscopic retrograde cholangiopancreatography versus primary LCBDE for managing cholecystocholedocholithiasis

“…Common bile duct (CBD) stones are found in approximately 5% to 20% of patients with symptomatic gallstones. 1 – 3 The optimal management of cholecystocholedocholithiasis is still under debate. Therapeutic strategies for CBD stones vary widely and include laparotomy, laparoscopic surgery, percutaneous intervention, and endoscopic retrograde cholangiopancreatography (ERCP).…”

“… 1 However, potential ERCP-related adverse effects include pancreatitis, duodenal perforation, and bleeding. 2 , 4 Moreover, the use of ERCP to extract CBD stones can fail for many reasons, including failed cannulation, previous Billroth II gastrectomy, large CBD stones, and high numbers of CBD stones. 5 Single-stage laparoscopic CBD exploration (LCBDE) during LC is now primarily used to treat cholecystocholedocholithiasis, although advanced surgical skills are required to perform the procedure.…”