Single-step treatment of gall bladder and bile duct stones: a combined endoscopis-laparoscopic technique

ABSTRACT

The advent of endoscopic techniques changed surgery in many regards. In the management of cholelithiasis laparoscopic cholecystectomy [LC] is today the treatment of choice. This has created a dilemma in the management of choledocholithiasis. Today a number of options exist for patients with suspected common bile duct [CBD] stones, these includes endoscopic sphincterotomy [ES] before LC stones, laparoscopic common bile duct exploration [LCBDE] by the trans-cystic approach or laparoscopic choledocotomy, open CBD exploration and post-operative ERCF. A major concern regarding both pre-and post-operative extraction of CBDS by the ERCP is the risk of development of pancreatitis, also more than 10% of the pre-operative ERCP are normal. More recently the alternative technique of combined LC with intraoperative ERCP [LC+IO-ERCP] and ES is emerging in an attempt to manage cholecysto-choledocholithiasis in a single-step procedure. The aim of this study was to assess the treatment of common bile duct stones [CBDS] in a one stage operation by Laparoscopic cholecystectomy [LC] and intraoperative endoscopic retrograde cholangio-pancreatography and endoscopic sphincterotomy [ES]. Fifteen patients with gall bladder stones and suspected, or confirmed CBDS were included in this study. They were treated by a single-step procedure combining LC and IO-ERCP. Laparoscopic intraoperative cholangiography [IOC] 'was carried out to confirm the presence of CBDS. A soft tipped guide wire was passed through the cystic duct and papilla into the duodenum. A papillotome was inserted endoscopically over the guide wire. Endoscopic sphincterotomy was performed and the stones were extracted with a retrieval balloon or a dormia basket. The surgical operating time, surgical success rate, postoperative complications, retained CBDS, and postoperative length of hospital stay were assessed. There were 10 females and 5 males. Their mean age was 45.07 +/- 11.3 years [ranged from 27 to 65years]. Nine patients had confirmed CBDS by preoperative ultrasound [US] and/or MRCP. Six patients were suspected for CBDS on clinical, laboratory and/or US basis. Conversion to open cholecystectomy occurred in one case due to severs adhesions at the Callot's triangle. The conversion rate in this study was accordingly 6.67%. IOC was performed in 14 patients and revealed the presence of CBDS in 12 patients. Cannulation of the papilla failed in one patient. IO-ERCF with ES was performed successfully in eleven patients and stones were extracted .endoscopically. Success rate was 91.67%. Cholecvstectomy was completed laparoscopicallv in 14 patients. The mean operative time was 119 +/- 14.4 mm [ranged from 100 to 150 mm]. Minor postoperative complications occured in 5 patients. No postoperative complications related to the procedure i.e. pancreatitis, bleeding, perforation were encountered. Patients regained their bowel motion on the next day and were discharged after a mean hospital stay of 2.55 +/- 0.89 days. None of the patients presented on the postoperative follow-up with symptoms, signs, laboratory or radiological evidence of retained CBDS. The mean duration of the postoperative follow-up was 9 +/- 4.07 months [ranged from 3 to 14 months]. The current study suggests that LC+JO-ER CF for the management of cholecysto-choledocholithiasis are a safe and effective technique with a low rate of post-ERCP pancreatitis. It offers another alternative for surgeons especially those who do not practice LCBDE to treat patients in a single setting. However, additional studies with larger patient populations are needed keeping in mind that the limiting characteristic is the proximity and availability of the endoscopic settings