Management Modalities of Choledocholithiasis: Endoscopic Retrograde Cholangiopancreatography Versus Open Common Bile Duct Exploration and Laparoscopic Cholecystectomy

Background and Objective : Common bile duct stone typically requires surgical intervention, which primarily involves open CBD exploration + Laparoscopic cholecystectomy, endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic CBD exploration. Open CBD exploration has multiple complications, high mortality rate and long recovery time. Methodology : A total of 50 cases presenting as choledocholithiasis between July 2018 to August 2020 were taken for study. 1st group of 20 patients underwent open cholecystectomy with open CBD exploration. 2nd group of 20 patients underwent ERCP followed by interval (6 weeks) laparoscopic cholecystectomy. Results : ERCP found to be better when compared with open CBD exploration in terms of less post-operative complications (5% in ERCP vs 20% in Open CBD exploration) and less mean duration of hospital stay(5 days in ERCP vs 8 days in Open CBD exploration). Interpretation and Conclusion : For management of CBD stone patient, gold standard treatment is ERCP followed by Laparoscopic Cholecystectomy. While in patients with incomplete clearance of CBD stone after ERCP, CBD exploration either laparoscopically or by open approach should be preferred. While in patients with CBD stone greater than 2 cm size, direct open CBD exploration is the preferred option380008

Experience with laparoscopic common bile duct exploration in failed endoscopic retrograde cholangiopancreatography cases at a tertiary care hospital

Background: Minimally invasive techniques for stone removal in common bile duct (CBD) are endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) or laparoscopic CBD exploration with LC (laparoscopic common bile duct exploration (LCBDE) and LC). Failed, multiple attempted or complications of ERCP leads to other surgical approaches where LCBDE is a preferable option by experts due to its added benefits.Methods:  We did LCBDE and LC in 40 cases of failed ERCP. Standard investigation protocol was followed in all cases and CBD were explored laparoscopically and stones were retrieved. Post retrieval choledochoscopy was done and sphincter of oddi was dilated by the dilators.Results: With careful selection of cases, stone calculi were retrieved successfully in 38 cases by laparoscopically and 2 cases by open method after conversion. Postoperative choledochoscopy were found normal. Bile leak seen in 3 cases, which were managed conservatively. Standard regime of postoperative care was taken followed by T-tube removal after cholangiogram on day 10-14. All patients survived the operation.Conclusion: We advocate that LCBDE is the most viable alternative for open surgery in failed ERCP cases for retrieval of CBD stones. This results in early recovery, better cosmetic scar, least complications with early resumption of routine life. Needs cautious patient selection and expertise in laparoscopic surgery.

Study on 60 cases of common bile duct stone, there different modality of management and its inference

Background: The aim of the study was to determine the best treatment modality for common bile duct stone become more challenging as large number of options available such as endoscopic, laparoscopic or open surgical methods, we need to choose specific therapy according to patient’s clinical conditions, and individual expertise.Methods: It is prospective study including 60 patient having common bile duct stone along with gall bladder stone, its different modality of management and its inference, conducted in Bhopal Memorial Hospital and Research Centre, Bhopal, during period of January 2017 to January 2020.Results: In 60 cases 41 patients undergoes to endoscopic retrograde cholangio pancreatography (ERCP) first, stone successfully removed in 34 patients and stent placed, one patients developed pancreatitis after ERCP, managed conservatively, In 6 patients retained stone after ERCP procedure, one patients developed surgical emphysema after procedure, managed with ICD and conservatively, and one patient had bleeding during sphincterotomy so its procedure abandoned and one of the patient failed to cannulate common bile duct (CBD).  21 patients undergo laparoscopic common bile duct explorations, 2 lap CBD exploration converted to open CBD exploration with cholecystectomy, due to adhesion at hepatocystic triangle. Five patients undergoes open CBD exploration, in one patient hepaticojejunostomy was done as patient was having CBD stone with stricture. No mortality during and after procedure.Conclusions: Management of CBD stone is depends upon individual expertise and available modality. If surgeons are expertise then lap CBD exploration with cholecystectomy without attempting to ERCP guide stone removal is best approach in majority of patients.

Minimally Invasive Surgery in Hepato-Biliary-Pancreatic Disease

The indication of laparoscopic procedure is continuously extending in the field of hepato-biliary-pancreatic surgery. Laparoscopic cholecystectomy has become a standard treatment for the disease of the gallbladder. Its application has widened to include conditions that once considered to be relative contraindications of laparoscopic cholecystectomy such as acute cholecystitis, complicated cholecystitis, previous operation history, and old age. Recently, a laparoscopic CBD exploration has been used for the treatment of CBD stone disease with good results. This operation may obviate the risk of immediate and long-term problem of sphincterotomy of the Ampulla of Vater resulting from endoscopic extraction of the CBD stone. For the biliary tract disease, pioneering operation of the laparoscopic IHD exploration and Roux-en-Y choledochojejunostomy have been successfully performed in our country. In terms of laparoscopic pancreatic surgery, a cystogastrostomy and a distal pancreatectomy are feasible operations. However, its indication is limited to benign or pre-malignant diseases. A pancreaticoduodenectomy with a laparoscopic technique is still not recommended. For the laparoscopic surgery of the liver, it has been initially applied to unroofing of a liver cyst or wedge resection. However, anatomic liver resections were successfully performed. The parenchymal dissection of the liver has been possible with the development of innovative laparoscopic equipments. Liver resection can be done with a laparoscopy-assisted method or a totally laparoscopic method. With accumulation of experience and the development of equipments, laparoscopic surgery has become a major operative tool in the hepato-biliary-pancreatic disease with an advantage of minimal invasiveness.

Comparative Study of Laparoscopic Common Bile Duct Exploration vs Open Method for the Treatment of CBD Stone

PURPOSE: To compare a laparoscopic common bile duct (CBD) exploration with the open method with regards to the clinical outcome in the treatment of a CBD stone. METHODS: A comparative study was performed on 88 patients who underwent surgical treatment for a CBD stone at Ewha Womans University Mokdong Hospital from February 1997 to December 2001. The patients were divided into three groups; a group treated by a laparoscopic CBD exploration (group L, n=59), a group treated by open surgery (group O, n=22), and a group converted to open surgery during laparoscopic treatment (group C, n=7). The medical records were reviewed, and the follow-ups study of the quality of life was assessed with a questionnaire on the symptoms associated with cholangitis. RESULTS: Among the 3 groups, there was no difference in the preoperative status of the patients (age, sex, preoperative comorbidity and previous abdominal operation history). The mean operating time were 230.7 minutes in group L, 182.0 minutes in group O, and 247.9 minutes in group C (P>0.05). The time to diet and hospital stay was longer in group C than the others (P<0.05). The postoperative complications were 10.5% in group L, 40.9% in group O and 14.3% in group C. The symptoms of cholangitis by the questionnaire during the follow-up period were 2.7% in group L, 33.3% in group O, and 66.7% in group C. CONCLUSION: Laparoscopic CBD exploration has acceptable operative difficulties, less morbidity, and good follow-up quality of life compared to the open method in treating CBD stones.