Download - Fanelli Laparoscopic Endobiliary Stent Robert D. Fanelli, MD, FACS Assistant Professor of Surgery University of Massachusetts Medical School Director of.

FanelliLaparoscopic Endobiliary StentFanelliLaparoscopic Endobiliary Stent

Robert D. Fanelli, MD, FACSAssistant Professor of Surgery

University of Massachusetts Medical SchoolDirector of Surgical Endoscopy

Berkshire Medical Center

Fanelli Laparoscopic Endobiliary StentFanelli Laparoscopic Endobiliary Stent

Laparoscopic Endobiliary Stent PlacementLaparoscopic Endobiliary Stent PlacementEliminates need for T-tubes, cystic duct catheters, external drains when Laparoscopic Transcystic Common Bile Duct Exploration (LTCBDE) or Laparoscopic Common Bile Duct Exploration (LCBDE) performed

Eliminates need for LTCBDE or LCBDE for Common Bile Duct Stones (CBDS)

Protects ductal closures, limits risks of bile leak


Laparoscopic Endobiliary Stent PlacementLaparoscopic Endobiliary Stent PlacementPrevents complications associated with retained CBDS

Virtually assures success of postoperative ERCP

Necessary equipment inexpensive, readily available

Suitable for use in ASCs as well as hospitals


Laparoscopic Endobiliary Stent PlacementLaparoscopic Endobiliary Stent PlacementFirst described as adjunct to LCBDE, eliminating T-tubes

16 patients (1993-1995)

100% clearance CBDS by LTCBDE and LCBDE

No bile leaks, complications

36 to 72 hour LOS

Gersin, Fanelli.Surgical Endoscopy, vol.12 (4),April 1998 p. 301.


Laparoscopic Endobiliary Stent PlacementLaparoscopic Endobiliary Stent PlacementMost surgeons rely on postoperative ERCP for CBDS

Patients face risks of retained CBDS, pancreatitis, cholangitis, stump leak

ERCP results vary based on volume High volume centers, > 95% selective cannulation rate Low volume centers, < 60% selective cannulation rate Average rates of selective cannulation, 80 to 85%

20% patients face reoperation, PTC, or referral for second ERCP for CBDS left at time of LC

Conversion, T-tubes, drains deprive patients of low morbidity, quick recovery of LC

T-tubes, drains require constant management, delay discharge


Laparoscopic Endobiliary Stent PlacementLaparoscopic Endobiliary Stent PlacementOur current experience (SSAT Scientific Session, May 2000)

372 consecutive LC during 36 months, ending July 1999

Hasson cannula, three 5 mm upper abdominal ports, general anesthesia, CO2 insufflation, routine fluorocholangiography (FC)

FC accomplished in all patients CBDS or suspicious FC identified in 48 (12.9%)

No attempt made to clear CBDS, all patients treated with stents

Stent placement added 9 to 26 minutes to LC operative time

Cystic duct balloon dilation necessary in 14 (29.2%)

Laparoscopic suturing, advanced skills were not utilized


Laparoscopic Endobiliary Stent PlacementLaparoscopic Endobiliary Stent PlacementHemorrhage, bile duct injury, duodenal perforation, sub-optimal stent placement, stent migration did not occur

Longest f/u 46 months; original series, 80 month f/u

44 (92%) treated as outpatients

4 (8%) admitted overnight with average LOS 30 hours Indications for admission:

PONV (2) surgery completed too late for discharge (1) weather too severe for safe discharge (1)

Outpatient ERCP with ES 1 to 4 weeks later 100% successful for clearance of CBDS CBDS found in all patients -- no false positive FC No ERCP, stent related complications to date, including pancreatitis


Laparoscopic Endobiliary Stent TechniqueLaparoscopic Endobiliary Stent Technique

Routine FC via epigastric port

Flexible tip cholangiogram catheter with three-way adapter

Three-way adapter permits saline, contrast injection, and placement of wire guide


Laparoscopic Endobiliary Stent TechniqueLaparoscopic Endobiliary Stent Technique150 cm Tracer Hybrid® Wire Guide advanced through cholangiogram catheter

Wire guide positioned across ampulla, past CBDS

Cholangiogram catheter, removed over wire guide

Finger occlusion of epigastric port prevents loss of CO2

Stent introducer port can be used if desired

Cystic duct dilated if necessary


Laparoscopic Endobiliary Stent TechniqueLaparoscopic Endobiliary Stent TechniqueContinuous fluoroscopy

Stent assembly advanced over wire guide

Position stent across ampulla

Radiographic markers assure proper positioning

Stent is fixed to delivery mechanism

Stent location adjusted as needed prior to deployment

Once position perfect, release safety to prepare for deployment


Laparoscopic Endobiliary Stent TechniqueLaparoscopic Endobiliary Stent TechniqueRadiographic markers

Marker 1 - distal tip Marker 2 - distal flange Marker 3 - proximal flange Marker 4 - proximal tip

Markers signal deployment Markers 3, 2, and 1 pass through

4 during release After 3, 2, and 1 clear 4, stent is

free of delivery system


Laparoscopic Endobiliary Stent TechniqueLaparoscopic Endobiliary Stent Technique Stent successfully deployed Positioned across ampulla Contrast rapidly drains from CBD Cystic duct ligated Cholecystectomy completed Drains are not placed Patient is discharged when alert

Placement of stent added 20 minutes to LC operative time


Laparoscopic Endobiliary Stent TechniqueLaparoscopic Endobiliary Stent TechniqueERCP 1 to 4 weeks postop

Same admission feasible

Various ERCP methods Snare removal of stent prior to

cannulation, sphincterotomy Wire guide placed via stent prior

to retrieval Precut sphincterotomy over stent Cannulate beside stent for

sphincterotomy (preferred method)


Laparoscopic Endobiliary Stent KitLaparoscopic Endobiliary Stent KitStent and pusher assembly

150 cm Tracer® Hybrid Wire Guide

Additional Components Introducer set 12 French cystic duct dilation balloon Cholangiogram catheter with three-way adapter, short wire


ConclusionsConclusionsThere are numerous methods for treating CBDS during LC

LCBDE is quick and highly successful, but requires refined laparoscopic suturing skills and carries risks of choledochotomy

LTCBDE is time consuming, requires expensive equipment and endoscopic, fluoroscopic skills, but avoids choledochotomy

Both employ external drains, T-tubes, or cystic duct catheters

Laparoscopic stent placement is fast, involves minimal expense, does not require choledochotomy, eliminates external tubes and drains, and virtually assures success of postoperative ERCP


ReferencesReferencesGersin KS, Fanelli RD. Laparoscopic Endobiliary Stenting as an Adjunct to Common Bile Duct Exploration. Surg Endosc 1998 Apr;12(4):301-304.

Fanelli RD, Gersin KS. Laparoscopic Endobiliary Stenting: A Simplified Approach to the Management of Occult Common Bile Duct Stones. J Gastrointest Surg 2001 Jan/Feb; 5(1):74-80.

Fanelli RD, Gersin KS, Mainella MT. Laparoscopic Endobiliary Stenting Significantly Improves Success of Postoperative ERCP in Low Volume Centers. Surg Endosc 2002 Mar;16(3):487-491.

Wu JS, Soper NJ. Comparison of Laparoscopic Choledochotomy Closure Techniques. Surg Endosc 2002 Sep;16(9):1309-1313.