Common Bile Duct Exploration for Choledocholithiasis

doi:10.1016/j.suc.2008.08.002

Surgical Clinics of North America

Volume 88, Issue 6, December 2008, Pages 1315-1328

https://doi.org/10.1016/j.suc.2008.08.002 Get rights and content

Laparoscopic common bile duct exploration has a high success rate, with rates reported from 83% to 96% in recent years. The morbidity rate has been reported to be approximately 10% Mortality rates are very low, at less than 1%.

Section snippets

Preoperative diagnosis and treatment

Choledocholithiasis is suspected preoperatively in those patients who have elevated liver function studies, jaundice, pancreatitis, radiologic signs of dilated intra- or extrahepatic ducts, or evidence of common bile duct stones by ultrasound. The most direct method of dealing with choledocholithiasis preoperatively is by endoscopic retrograde cholangiopancreatography (ERCP). ERCP first was reported in 1974 and has gained widespread usage. Decompression of the ductal system can be achieved by

Intraoperative diagnosis and treatment

If the patient has a history of elevated liver function tests or biliary pancreatitis preoperatively, it is important to perform an intraoperative cholangiogram to rule out persistent common bile duct stones. If stones are found during the course of a laparoscopic cholecystectomy, there are three ways of proceeding: laparoscopic common bile duct exploration (LCBDE), conversion to an open common bile exploration (CBDE), or completion of the cholecystectomy with postoperative ERCP. The inherent

Postoperative diagnosis and treatment

Occasionally, the patient will have no signs of common bile duct obstruction and a normal cholangiogram intraoperatively (or one is not performed), yet develop signs of choledocholithiasis postoperatively. Most frequently this is because of a stone being pushed down from either the gallbladder or cystic duct into the common bile duct in the course of performing a laparoscopic cholecystectomy. Because the surgery is already complete, the most sensible option for the patient is to undergo ERCP

Preoperative imaging

Radiologic assessment of the bile ducts has improved in the past decade. Transabdominal ultrasound often is used as a screening test for common bile duct stones; however, it is not extremely sensitive (sensitivity 0.3, specificity 1.00) [10], [11], [12]. In combination with clinical symptoms and laboratory abnormalities, ultrasound examination can help select the patients who need further imaging. With high specificity, if an ultrasound is negative and liver function tests are normal, there is

Indications for common bile duct exploration

Common bile duct exploration is done based on the results of an intraoperative cholangiogram (IOC) or sonogram. Some surgeons advocate for IOC in every patient, because they would argue that, in addition to demonstrating the presence of common bile duct stones, it provides a map of the anatomy and decreases the incidence of bile duct misadventures. On the other hand, many feel that with a good preoperative history, appropriate laboratory tests, and preoperative imaging, extra biliary

Open common bile duct exploration

The first open common bile duct exploration was described in 1889 by New York surgeon Robert Abbé. He opened the duct of a 36-year-old woman with severe jaundice, removed a stone, sewed the duct closed with fine silk, and returned her to perfect health. Other sources give credit for the first exploration to Londoner J.K. Thornton, Swiss surgeon Ludwig Courvoisier, or Herman Kümmell of Hamburg, Germany [19].

Although very rare today given the success of stone removal by means of endoscopic or

Laparoscopic common bile duct exploration

Because over 80% of gallbladders are removed laparoscopically, laparoscopic common bile duct exploration is being performed with increasing frequency. It is a difficult procedure, however, that requires a great deal of laparoscopic skill. Therefore it only is done by a select group of laparoscopic surgeons. The advantages are clear; the gallbladder and stones are taken care of simultaneously in a minimally invasive manner that leads to shorter hospital stays and less pain than the corresponding

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Cited by (58)

Horseshoe kidney leading to ERCP failure; innovative use of guide wire during laparoscopic CBD exploration: A case report
2021, International Journal of Surgery Case Reports
Horseshoe kidneys are the most common fusion defect of the kidneys, which amounts to about 0.25% of the population. They are usually asymptomatic and are often identified incidentally. The horseshoe kidney can push the second and third part of the duodenum anteriorly, leading to an altered CBD course. Choledocholithiasis is seen in approximately 10‐15% of patients with cholelithiasis. Presently, the most preferred approach for managing CBD stones is ERCP. However, in ERCP failure cases, Laparoscopic CBD exploration is the primary treatment modality, with or without T-tube use, with all the advantages of minimally invasive surgery.
A 65-year-old female presented with complaints of pain in the right hypochondriac region for three months associated with nausea, jaundice, and loss of appetite and weight. Her USG abdomen showed cholelithiasis with dilated CBD with horseshoe kidney with severe hydronephrosis of the left kidney. They are usually asymptomatic and are often identified incidentally. In this patient, it was believed that the horseshoe kidney had pushed the second and third part of the duodenum anteriorly, leading to an altered CBD course leading to ERCP failure. MRCP confirmed cholelithiasis with choledocholithiasis with dilated CBD of 11.3 mm with horseshoe kidney. ERCP was attempted but was unsuccessful due to non-visualization of the papilla due to overcrowding of duodenal folds.
For patients with ERCP failure, laparoscopic CBD exploration is mandatory. For this patient, the CBD was cannulated with a guidewire, if needed, for repeat ERCP and was closed with T-tube in situ.
There are no particular preoperative indicators that can predict the failure of ERCP. However, in ERCP failure cases, laparoscopic CBD exploration (with or without T-tube use) is the primary treatment modality.
Surgical (Open and laparoscopic) management of large difficult CBD stones after different sessions of endoscopic failure: A retrospective cohort study
2019, Annals of Medicine and Surgery
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.
We analyzed 85 patients underwent surgical management of difficult CBDS after ERCP failure, in the period from 2013 to 2018.
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.
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.
Technical Aspects of Bile Duct Evaluation and Exploration: An Update
2019, Surgical Clinics of North America
Citation Excerpt :
This article focuses on the technical aspects of surgical exploration of the CBD for CD. Ten percent to 15% of patients with symptomatic cholelithiasis present with concurrent CD.1 Cholecystectomy and intraoperative cholangiography (IOC) or intraoperative ultrasound (IOUS) are recommended as the first step in managing these patients so long as they are fit for surgery.2
An Update on Technical Aspects of Cholecystectomy
2019, Surgical Clinics of North America
Various approaches of laparoscopic common bile duct exploration plus primary duct closure for choledocholithiasis: A systematic review and meta-analysis
2018, Hepatobiliary and Pancreatic Diseases International
Citation Excerpt :
The pooled estimates of ORs showed difference between CME + PDC and CE + PDC (OR = 0.17; 95% CI: 0.04, 0.74; P < 0.05) (Fig. 7C). Treatment of choledocholithiasis had evolved from the first choledocolithotomy described in 1889 by Robert Abbé [36]. Almost a century later in 1985 the first laparoscopic cholecystectomy was performed [37].
Common bile duct (CBD) stones may occur in up to 3%–14.7% of all patients with cholecystectomy. Various approaches of laparoscopic CBD exploration plus primary duct closure (PDC) are the most commonly used and the best methods to treat CBD stone. This systematic review was to compare the effectiveness and safety of the various approaches of laparoscopic CBD exploration plus PDC for choledocholithiasis.
Randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) (case-control studies or cohort studies) were searched from Cochrane library (until Issue 2, 2015), Web of Science (1980-January 2016), PubMed (1966-January 2016), and Baidu search engine. After independent quality assessment and data extraction, meta-analysis was conducted using RevMan 5.1 software.
Four RCTs and 18 NRCTs were included. When compared with choledochotomy exploration (CE) plus T-tube drainage (TTD) (CE + TTD), CE plus PDC (CE + PDC) and CE + PDC with biliary drainage (BD) (CE + PDC + BD) had a lower rate of postoperative biliary peritonitis (OR = 0.22; 95% CI: 0.06, 0.88; P < 0.05; OR = 0.27; 95% CI: 0.08, 0.84; P < 0.05; respectively) where T-tubes were removed more than 3 weeks. The operative time of CE + PDC was significantly shorter (WMD = -24.82; 95% CI: −27.48, −22.16; P < 0.01) than that of CE + TTD in RCTs. Cystic duct exploration (CDE) plus PDC (CDE + PDC) has a lower rate of postoperative complications (OR = 0.39; 95% CI: 0.23, 0.67; P < 0.01) when compared with CE + PDC. Confluence part micro-incision exploration (CME) plus PDC (CME + PDC) has a lower rate of postoperative bile leakage (OR = 0.17; 95% CI: 0.04, 0.74; P < 0.05) when compared with CE + PDC.
PDC with other various approaches are better than TTD in the treatment of choledocholithiasis.
Efficiency of laparoscopic vs endoscopic management in cholelithiasis and choledocholithiasis. Is there any difference?
2017, Cirugia y Cirujanos (English Edition)
La colelitiasis y coledocolitiasis concomitante es una enfermedad que aumenta su incidencia con la edad y puede presentar complicaciones graves como: pancreatitis, colangitis o abscesos hepáticos. Su manejo es controversial, ya que existen métodos de mínima invasión laparoscópicos y endoscópicos.
Comparar la eficiencia en el manejo de colelitiasis y coledocolitiasis con colecistectomía laparoscópica con exploración de vía biliar vs. colangiopancreatografía retrógrada endoscópica + colecistectomía laparoscópica.
Análisis retrospectivo de 5 años observacional, transversal, multicéntrico, de pacientes con colelitiasis y alto riesgo de coledocolitiasis, quienes se dividieron en 2 grupos, y se comparó la eficiencia de ambos procedimientos. El grupo 1 fue manejado con colecistectomía laparoscópica con exploración de vía biliar y el grupo 2 con colangiopancreatografía retrógrada endoscópica + colecistectomía laparoscópica.
Se incluyó a 40 pacientes, 20 de cada grupo, se encontró una p = 0.10 en cuanto al tiempo quirúrgico, al comparar los días de hospitalización se encontró una p = 0.63, el éxito de la extracción de litos por grupo de estudio obtuvo una p = 0.15, las complicaciones presentadas por grupo mostraron una p = 0.1 y el número de hospitalizaciones por grupo presento una p ≤ 0.05, demostrando significación estadística.
Ambos abordajes presentan la misma eficiencia para el manejo de la colelitiasis y coledocolitiasis en cuanto al tiempo quirúrgico, éxito en la extracción de lito, días de hospitalización, complicaciones postoperatoria y conversión a cirugía abierta, sin embargo, el abordaje laparoscópico es favorable, ya que disminuye el número de eventos anestésico-quirúrgicos y el número de internamientos hospitalarios.
Concomitant cholelithiasis and choledocholithiasis is a disease where incidence increases with age and can have serious complications such as pancreatitis, cholangitis and liver abscesses, but its management is controversial, because there are minimally invasive laparoscopic and endoscopic surgical procedures.
To compare the efficiency in the management of cholelithiasis and choledocholithiasis with laparoscopic cholecystectomy with common bile duct exploration vs cholangiopancreatography endoscopic retrograde + laparoscopic cholecystectomy.
Retrospective analysis of a five year observational, cross sectional multicenter study of patients with cholelithiasis and concomitant high risk of choledocholithiasis who were divided into two groups and the efficiency of both procedures was compared. Group 1 underwent laparoscopic cholecystectomy with common bile duct exploration and group 2 underwent cholangiopancreatography endoscopic retrograde + laparoscopic cholecystectomy.
40 patients, 20 were included in each group, we found p = 0.10 in terms of operating time; when we compared hospital days we found p = 0.63; the success of stone extraction by study group we obtained was p = 0.15; the complications presented by group was p = 0.1 and the number of hospitalizations by group was p ≤ 0.05 demonstrating statistical significance.
Both approaches have the same efficiency in the management of cholelithiasis and choledocholithiasis in terms of operating time, success in extracting stone, days of hospitalization, postoperative complications and conversion to open surgery. However the laparoscopic approach is favourable because it reduces the number of surgical anaesthetic events and the number of hospital admissions.

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Common Bile Duct Exploration for Choledocholithiasis

Section snippets

Preoperative diagnosis and treatment

Intraoperative diagnosis and treatment

Postoperative diagnosis and treatment

Preoperative imaging

Indications for common bile duct exploration

Open common bile duct exploration

Laparoscopic common bile duct exploration

Am J Surg

Clin Radiol

HPB

Guidelines on the management of common bile duct stones

Gut

Prospective evaluation of the use of endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy

Endoscopy

Preoperative bilirubin, alkaline phosphatase, and amylase levels as predictors of common duct stones

Surg Gynecol Obstet

Preoperative evaluation of the risk of common bile duct stones

Arch Surg

Selective preoperative endoscopic retrograde cholangiography with sphincterotomy avoids bile duct exploration during laparoscopic cholecystectomy

Gut

A prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of choledocholithiasis revisited

Ann Surg

Common bile duct stones

Surgical versus endoscopic treatment of bile duct stones

Cochrane Database Syst Rev

Predicting the presence of choledocholithiasis in patients with symptomatic cholelithiasis

Am J Gastroenterol

Prediction of common bile duct stones prior to cholecystectomy: a prospective validation of a discriminant analysis function

Arch Surg