300 Laparoscopic Bile Duct 300 Laparoscopic Bile Duct ExplorationsExplorations

Results and ComplicationsResults and Complications

Ahmad NassarAhmad NassarLaparoscopic and Upper GI Service Laparoscopic and Upper GI Service

Monklands HospitalMonklands Hospital Lanarkshire , ScotlandLanarkshire , Scotland

IntroductionIntroduction

EAES ductal stone study EAES ductal stone study (December 1996)(December 1996)Multi-centre prospective randomized trialMulti-centre prospective randomized trialSingle stage vs. 2 stage CBD clearanceSingle stage vs. 2 stage CBD clearance– Equal success ratesEqual success rates– Shorter hospital stay for single stageShorter hospital stay for single stage– Cost benefitsCost benefits

Scottish SurveyScottish Survey

Questionnaire sent to Scottish surgeonsQuestionnaire sent to Scottish surgeonsTwice 5 years apartTwice 5 years apartResponse:Response:– 157 in 1998 (Group A)157 in 1998 (Group A)– 77 in 2002 (Group B)77 in 2002 (Group B)

Laparoscopic exploration was available to:Laparoscopic exploration was available to:– 14.6% of surgeons Group A (by themselves)14.6% of surgeons Group A (by themselves)– 33.8% of surgeons Group B (by themselves)33.8% of surgeons Group B (by themselves)

Scottish SurveyScottish Survey

Although more Although more surgeons capable, surgeons capable, less willing to doless willing to doLaparoscopic Laparoscopic exploration was exploration was considered the future considered the future by 26 surgeons in by 26 surgeons in Group A, but only 18 Group A, but only 18 surgeons in Group Bsurgeons in Group B

LBDELBDE Group AGroup A Group B Group B

Non-Non-responderresponder

36 (22.9%)36 (22.9%) 4 (5.2%)4 (5.2%)

All-comersAll-comers 2 (1.3%)2 (1.3%) 0 (0%)0 (0%)

OftenOften 3 (1.9%)3 (1.9%) 3 (3.9%)3 (3.9%)

OccasionalOccasional 18 (11.5%)18 (11.5%) 29 (37.6%)29 (37.6%)

NeverNever 98 (62.4%)98 (62.4%) 41 (53.2%)41 (53.2%)

Patients and MethodsPatients and Methods

Prospective study over 13 years Prospective study over 13 years One stage management of all-comers One stage management of all-comers including biliary emergenciesincluding biliary emergenciesFour trocar laparoscopic accessFour trocar laparoscopic accessRoutine intraoperative cholangiogramRoutine intraoperative cholangiogramTranscystic attempts at duct clearance Transcystic attempts at duct clearance initiallyinitiallyFollowed by dochotomy Followed by dochotomy ± drainage± drainage

Patients and MethodsPatients and Methods

1680 biliary procedures on a referral firm1680 biliary procedures on a referral firmAll suspected ductal calculi and most other All suspected ductal calculi and most other emergenciesemergencies300 bile duct explorations300 bile duct explorations– Transcystic approach 169 patientsTranscystic approach 169 patients– Dochotomy 131 patientsDochotomy 131 patients

Glucagon + flushing attemptedGlucagon + flushing attempted Followed by trawling with DormiaFollowed by trawling with Dormia Prior to choledochoscopic explorationsPrior to choledochoscopic explorations

ResultsResultsLap. Explorations (300)Lap. Explorations (300)Emergency admissions Emergency admissions 201 (66%)201 (66%)

Explorations in last 5 years Explorations in last 5 years 216 (72%)216 (72%)

Bile duct stone suspicion Bile duct stone suspicion 243 (81%)243 (81%)

Mean age 59.1 yearsMean age 59.1 years

Whole series (1680)Whole series (1680)Emergency admissions Emergency admissions for series 501 (29.8%)for series 501 (29.8%)

Preceding 8 years 84 Preceding 8 years 84 (32.3%)(32.3%)

Bile duct stone suspicion Bile duct stone suspicion 490 (30%)490 (30%)

Mean age 50.5 yearsMean age 50.5 years

ResultsResults

Intraoperative Intraoperative cholangiogram –ve in cholangiogram –ve in 252 patients out of 252 patients out of 501 with suspicious 501 with suspicious CBD stones (50.3%)CBD stones (50.3%)IOC positive in 92 IOC positive in 92 patients with no CBD patients with no CBD stone suspicion stone suspicion n=1170 (7.8%).n=1170 (7.8%).

PresentationsPresentations Lap. Explorations Lap. Explorations (n= 300)(n= 300)

JaundiceJaundice 131131

CholangitisCholangitis 2424

PancreatitisPancreatitis 2121

U/S U/S dilatation/stonesdilatation/stones

182182

Deranged LFTsDeranged LFTs 111111

CBD stone riskCBD stone risk 228228

Results – Biliary DrainageResults – Biliary DrainageNo DrainNo Drain Cystic duct Cystic duct

draindrainT-tubeT-tube

TCETCE 109109 5757 --

CBDECBDE 3030 6161 4040

* Converted* Converted 10 (3 bypass)10 (3 bypass) -- 44

ConversionsConversionsDateDate AgeAge SexSex TypeType CauseCause ProcedureProcedureSept 92Sept 92 4242 MM TCETCE No instruments for cbdeNo instruments for cbde Open CBDEOpen CBDE

April 93April 93 4242 FF CBDCBD Large impacted stonesLarge impacted stones OpenOpen

April 93April 93 4040 FF CBDCBD Large impacted stonesLarge impacted stones Open BypassOpen Bypass

Dec 94Dec 94 7474 FF CBDCBD Stricture/ ? malignantStricture/ ? malignant Open BypassOpen Bypass

May 95May 95 3939 FF CBDCBD Impacted stonesImpacted stones Open BypassOpen Bypass

June 95June 95 6565 FF CBDCBD Multiple 30+, 2 impactedMultiple 30+, 2 impacted Open CBDEOpen CBDE

June 97June 97 7878 FF CBDCBD ImpactedImpacted Open BypassOpen Bypass

Sept 97Sept 97 3737 FF CBDCBD 60 stones+ 2 impacted60 stones+ 2 impacted Open CBDEOpen CBDE

June 02June 02 71 71 FF CBDCBD DONE, SB adhesions at DONE, SB adhesions at umbilicus, denseumbilicus, dense

Release Release resectionresection

Feb 04Feb 04 2626 MM CBDCBD DONE Mirizzi 2 needing DONE Mirizzi 2 needing BypassBypass

Results and ComplicationsResults and ComplicationsMean Mean

difficultydifficultyMean operating Mean operating

timetimeSubhepatic Subhepatic

draindrainFeverFever Wound Wound

infectioninfectionBiliary leakBiliary leak

TCETCE169169

2.492.49 145.1 min145.1 min 12812875%75%

33 55 33

CBDECBDE131131

2.682.68 197.4 min197.4 min 123123 22 11 66

ConvertedConverted10 3.3%10 3.3%

3.913.91 272 min272 min 99 11 11 11

TCE= transcystic explorationTCE= transcystic explorationCBDE= common bile duct explorationCBDE= common bile duct explorationOpen= conversion to openOpen= conversion to open

Morbidity ParametersMorbidity Parameters

Retained stones: 11 3.6%Retained stones: 11 3.6%Postoperative ERCP ( all causes): 24 8%Postoperative ERCP ( all causes): 24 8%Recurrent Stones: 5 1.6%Recurrent Stones: 5 1.6%Re-operation: 3 1%Re-operation: 3 1%Mortality: 1 0.3%Mortality: 1 0.3%

- SMA ischaemia/ infarction- SMA ischaemia/ infarction

Results - MeansResults - Means

6.22

11.6

16

1.913.57

5.09

0

2

4

6

8

10

12

14

16

H. Stay (days) Pres-Res (weeks)

TCECBDEOpen

DiscussionDiscussion

Previous studies have proved cost-Previous studies have proved cost-effectiveness and decreased hospital stay effectiveness and decreased hospital stay for laparoscopic biliary explorationfor laparoscopic biliary explorationSurgeons who overcome learning curve Surgeons who overcome learning curve are still reluctant to adopt techniqueare still reluctant to adopt technique51.3% of patients who have clinical, 51.3% of patients who have clinical, ultrasound or biochemical suspicion of ultrasound or biochemical suspicion of duct stones would have unnecessary duct stones would have unnecessary preoperative investigationspreoperative investigations

DiscussionDiscussionEight percent silent stones were picked up Eight percent silent stones were picked up by routine intraoperative cholangiogramby routine intraoperative cholangiogramTranscystic ductal exploration:Transcystic ductal exploration:– Clearance achieved with glucagon, flushing Clearance achieved with glucagon, flushing

and Dormia trawling in 32.2% of patientsand Dormia trawling in 32.2% of patients– Less morbidityLess morbidity– Decreased operative time, shorter hospital Decreased operative time, shorter hospital

stay and shorter presentation-resolution than stay and shorter presentation-resolution than choledochotomycholedochotomy

– Also facilitates simple postoperative biliary Also facilitates simple postoperative biliary drainagedrainage

ConclusionConclusion

Laparoscopic single session management Laparoscopic single session management of ductal stones is cost-effective with of ductal stones is cost-effective with shorter hospital stay than multiple stage shorter hospital stay than multiple stage managementmanagement Simple transcystic manoeuvres may clear Simple transcystic manoeuvres may clear the ducts without formal explorationthe ducts without formal exploration This technique is advocated in preference This technique is advocated in preference to endoscopic clearance for surgeons to endoscopic clearance for surgeons beyond the learning curvebeyond the learning curve