Single-stage laparoscopic management for concomitant

gallstones and common bile duct stones versus two stages using ERCP

procedures

By:

Mohamed Tag El-Din Mohamed

General surgery specialist

Qena general hospital

Protocol Submitted for partial fulfillment of Doctor Degree in General

surgery

Under supervision of

Prof. Dr. Alaa Ahmed Redwan Professor of GIT surgery and laparoendoscopy

Faculty of medicine, Sohag University

Dr. Magdy Khalil Abd El-Mageed

Assistant professor of general surgery

Faculty of medicine, Sohag University

Dr. Ahmed Abd El-Kahaar Aldardeer

Lecturer of general surgery

Faculty of medicine, Sohag University

2017

Introduction O Gallbladder stone is a common cause for

abdominal pain.

O Gallstones are rarely an indication for

surgery, but 10% of the adult population live

with them without any related complications.

O Furthermore, 30% of the population over 70

years of age will have gallstone.

(Kenny R et al, 2014)

O As many as 35% of patients with gallstones will

ultimately become symptomatic and require

cholecystectomy.

O Gallstones can sometimes migrate out of the

gallbladder and become trapped in common bile

duct .

(Dasari et al, 2013).

O CBD stones is concomitant with

gallstones in approximately 3%-10% of

the patients.

O Between 10% and 18% of people

undergoing cholecystectomy for

gallstones have common bile duct stones.

(Bansal et al, 2014).

Clinical presentation

O Stones within the bile duct are often

asymptomatic and may be found

incidentally, however, more frequently

they lead to symptomatic presentation

with:

oBiliary colic

oAscending cholangitis

oObstructive jaundice

oAcute pancreatitis(Bansal et al, 2014).

Radiographic features

1. Ultrasound

O Sensitivity has been variably reported

between 13-55% .

O Findings include:

O Visualization of stone

O Dilated bile duct

(Frank Gaillard et al,2016)

2. CT abdomen

O Sensitivity of 65-88%

O Findings include

o Target sign: central rounded density stone surrounding

lower attenuating bile or mucosa

o Rim sign: stone is outlined by thin shell of density

o Crescent sign: bile eccentrically outlines luminal stone,

creating a low attenuation crescent

o Calcification of the stone: unfortunately only 20% of

stones are of high density

(Frank Gaillard et al,2016)

3. MRCP

O Sensitivity (90-94%) and specificity (95-

99%)

O Findings include Filling defects are seen

within the biliary tree

(Frank Gaillard et al,2016)

Management

O In the pre-endoscopy and pre-laparoscope

era, the standard treatment for patients

suffering from gallstones accompanied with

common bile duct stones was open

cholecystectomy and common bile duct

exploration.

(Bansal et al, 2014).

Open exploration of CBDO Kocher incision

O Choledochotomy Incision

O Exploring the CBD

O Extraction of stones

O Cholecystectomy

O Insertion of the T-Tube

O Drainage and Closure

(Carol E. H et al, 2013)

ERCPO With all the breakthrough of endoscopic

retrograde cholangiopancreatography

(ERCP), endoscopic stone removal grew

to become the treating preference for

removal of CBD stones .

O Two-stage management using ERCP

accompanied by laparoscopic

cholecystectomy is a very common

technique for treatment of gall bladder

and CBD stones.

(Pankaj Prasson et al, 2016).

O ERCP is a procedure that enables to

examine the pancreatic and bile ducts.

O An endoscope about the thickness of

index finger is placed through mouth and

into stomach and first part of duodenum.

(Pankaj Prasson et al, 2016).

O In the duodenum a small opening is

identified (ampulla) and a small plastic

tube (cannula) is passed through the

endoscope and into this opening.

O Dye (contrast material) is injected and X-

rays are taken to study the ducts of the

pancreas and liver.

(Pankaj Prasson et al, 2016).

O Another open channel in the endoscope

also allows other instruments to be

passed through it in order to perform

biopsies, to insert plastic or metal stents

or tubing to relieve obstruction of the bile

ducts, and to perform incisions by using

electrocautery.

(Pankaj Prasson et al, 2016).

Laparoscopic exploration of CBD

O The laparoscopic common bile duct

exploration is a potential option for

managing stones within the biliary tree at

the same time as laparoscopic

cholecystectomy.

(Pankaj Prasson et al, 2016).

O The procedure is performed with the

patient in the supine position, with the

surgeon on the patient’s right and the

assistant on the left.

O the laparoscopic monitor are placed at the

patient’s head to the right.

(Bansal et al, 2014).

Port sites

The 5.5-mm rigid choledochoscope was inserted through the

epigastric port

The bile duct stone was extracted via basket at the direct view.

Use the laparoscopic interrupted sutures to close the

choledochotomy.

Aim of WorkO The aim of this study is to compare between

the outcome of management of concomitantgallstones and common bile duct by two stage(ERCP+LC) versus one stage(LECBD+LC) asregard:

Intraoperative complications

Conversion to other procedure

Total operative time

Postoperative complications

Postoperative mortality

Retained CBD stones

Length of hospital stay

Patient satisfaction

Patients and Methods

O This retrospective and prospective study

will include patients with concomitant

gallstones and common bile duct in

General surgery department in sohag

university hospital.

Criteria for inclusion

1. Age 16 to 70 years.

2. Patients with gallbladder stones and

concomitant stones in the CBD.

3. Patients with or without Jaundice.

Criteria for exclusion

1. Acute cholecystitis.

2. Acute pancreatitis.

3. Uncorrectable coagulopathy.

4. Liver cirrhosis, mass or abscess.

5. Recurrent choledocholithiasis.

6. Malignant pancreatic or biliary tumors.

Preoperative Preparation1. Routine investigations in form of: complete

blood picture, prothrombin time and

concentration, blood glucose, serum

creatinine , complete liver functions,

serology, blood typing.

2. Radiological investigations in form of

abdominal U/S and MRCP.

3. Written informed consent will be taken from

all patients.

Operative managementO Group I patients underwent single-stage

laparoscopic CBD exploration (LCBDE)

and laparoscopic cholecystectomy (LC).

O Group II patients underwent a two-stage

procedure; ERCP for endoscopic

extraction of CBD stones followed by LC

(ERCP + LC) within the same hospital

admission.

Postoperative management

O Postoperatively, the patients were

followed up at 1 week, 2 weeks, 3 weeks,

6 week, and up to 3months by:

O clinically: pain, fever, jaundice, wound

condition

O laboratory: liver function test

O investigatory: abdominal U/S

O At a 6-week follow-up evaluation, overall

satisfaction was assessed on a verbal

rating scale with scores of 0 (not

satisfied), 1 (partially satisfied), 2

(satisfied), or 3 (very satisfied).

Primary end point:

O Defined as removal of CBD stones and

gallbladder by the intended approach

Secondary end points

O Intraoperative complications: CBD injury

O Operative time in minutes

O Postoperative complications: bile leak, hemorrhage,

pancreatitis

O Pain score: The pain score was calculated on a

visual analog scale ranging from 1 to 10.

O Hospital stay: The hospital stay was calculated in

group I as the number of days in the hospital after

surgery until the patient was discharge and in

group II as the total duration of stay for ERCP and

cholecystectomy.

O Patient satisfaction score: Patient satisfaction was

scored on a verbal rating scale with scores of 0

(not satisfied), 1 (partially satisfied), 2 (satisfied),

and 3 (very satisfied)