Short-Term Outcomes of Laparoscopic Transcystic Common Bile Duct Exploration with Discharge Less Than 24 Hours

Introduction

The incidence of choledocholithiasis in patients with symptomatic gallstones has been reported to be 10% and up to 15% in patients with acute cholecystitis. ¹ A short hospital stay is one of the main advantages of laparoscopic surgery. ² With the improvements of laparoscopic transcystic technology, analgesia, and anesthetics, a decline in the length of hospital stay after the surgery occurs when an increasing pressure on hospital resources becomes more and more severe. ³ Advances in surgical techniques also contribute to a shorter period of convalescence and an earlier return to work. ⁴ Reducing the length of stay and discharge time for patients could benefit multiple hospital units by saving money, reducing infection rates and operating room waiting time, and providing the opportunity for more patients to be treated. ⁵ Indeed, there is a trend toward performing day-case surgery on patients with complex medical conditions,^2,5 such as acute cholecystitis, which may develop acute obstructive suppurative cholangitis. ⁶ Before the development of day surgery for choledocholithiasis, assessment of overnight stay less than 24 hours is necessary. However, no experience of laparoscopic transcystic common bile duct (CBD) exploration (LTCBDE) with discharge less than 24 hours has been reported until now.

The objective of this study was to assess the feasibility and safety of LTCBDE with discharge less than 24 hours.

Patients and Methods

Between June 1 and December 31, 2011, of 111 patients scheduled in our institution, 34 patients were discharged in less than 24 hours after LTCBDE. The sufficient assessment of operative risk was made according to blood examinations, electrocardiograms, chest X-rays, and abdominal ultrasounds. Magnetic resonance cholangiopancreatography was performed routinely to detect CBD stones in order to plan the procedure.

Operative techniques

LTCBDE was performed by two experienced surgeons with the patients under general anesthesia. A carbon dioxide pneumoperitoneum was created via a 10-mm port inserted at the umbilicus. Views were obtained through a 10-mm 30° laparoscope, and the pneumoperitoneum was maintained at a pressure of 12 mm Hg. After insufflation, the patient was positioned in a reverse Trendelenburg position tilted to the left. Three additional trocars were then positioned: a 10-mm port in the epigastrium and two 5-mm ports in the right hypochondrium. A wide local dissection of Calot's triangle was performed, and the cystic artery was clipped and cut off. After the bile duct was clipped 1 cm away from the CBD, a transverse incision was made in the lateral wall of the cystic duct (Fig. 1A). After dilation with the tip of the forceps, one or two sutures were made to expose the cystic duct. Then a 3-mm or 5-mm flexible choledochoscope, according to the diameter of the cystic duct, was inserted through the hypochondrium sheath into the CBD (Fig. 1B). The stones were retrieved individually in a wire basket through the choledochoscope (Fig. 1C). Saline flushing was used in the case of multiple relatively small stones in the CBD. When the stones larger than the cyst duct were not retrieved, an incision (about 3–5 mm) was made into the cystic duct and its confluence part. Once the stones had been retrieved, the incision was sutured. Then laparoscopic cholecystectomy was performed from the gallbladder bed after the cystic duct had been clipped and divided (Fig. 1D). No abdominal drain was placed.

OPEN IN VIEWER

FIG. 1.

(A) After the bile duct was clipped 1 cm away from the common bile duct, a transverse incision was made in the lateral wall of the cystic duct. (B and C) After dilation with the tip of the forceps, one or two sutures were made to expose the cystic duct. Then a 3-mm or 5-mm flexible choledochoscope, according to the diameter of the cystic duct, was inserted into the common bile duct. The stones were retrieved individually in a wire basket through the choledochoscope. (D) The cystic duct was ligated with two Hem-o-loks once the stones had been retrieved.

Results

A single-step treatment combining laparoscopic cholecystectomy and LTCBDE was attempted in a total of 111 patients admitted for cholelithiasis. The success rate was 80.2%. The 22 failed LTCBDEs were due to friable cystic ducts (10 patients), long parallel cystic ducts (7 patients), and severe adhesions at the triangle of Calot (5 patients).

Of the 89 patients treated successfully, 34 patients were discharged within 24 hours postoperatively. This population comprised 11 (32.4%) males and 23 (67.6%) females with a mean age of 54.6±14.7 years (range, 28–79 years). All the 34 patients were diagnosed of gallbladder stones by ultrasound and choledocholithiasis by magnetic resonance cholangiopancreatography. The main clinical feature was biliary colic, and 38% of the patients had complications of other unrelated diseases, especially in the older patients. Seven patients with previous abdominal operation underwent the procedure successfully (Table 1).

In the surgery, a 3-mm-diameter choledochoscope was used in 33 cases, and the 5-mm-diameter device was used in only 1 case. According to the shape and diameter of the CBD stones, a combination of saline flushing, basket, and microincision was used to remove CBD stones. Flushing the floccules, sediments, and stones with a diameter of 1 mm or less was easier, but more time was needed to confirm the clearance than with the basket extraction, which was done for the stones of more than 1 mm in diameter. Only 1 patient underwent a microincision for a 6-mm-diameter stone. The number of CBD stones was no more than three, and the diameter was no more than 6 mm. The mean diameter of the CBD was 7.9 mm. The mean postoperative stay was 20.21±2.29 hours (range, 14 hours 35 minutes–23 hours 50 minutes) (Table 2).

All the patients showed active bowel sounds and had flatus before discharge. No one was lost to follow-up. The 30-day morbidity and mortality rates of the 34 cases were 0%. There were no postoperative complications or deaths among the studied group during the hospital stay or by the 12-month postoperative follow-up. However, of the other 77 patients, 2 patients having recurrence of CBD stones were cured by endoscopic retrograde cholangiopancreatography (ERCP) about 6 months after the operation.

Discussion

There are various methods to treat choledocholithiasis, including the simple transcystic approach, directly through a choledochotomy, and ERCP. Some randomized clinical trials have suggested that laparoscopic CBD exploration and ERCP have similar rates of stone clearance, morbidity, and mortality. ⁷ However, when LTCBDE and laparoscopic CBD exploration are used as a single-session approach to treat choledocholithiasis, the procedure is associated with a shorter hospital stay and is more cost-effective compared with ERCP.^8,9 Although LTCBDE is less invasive and has proved to be safe and efficient, ¹⁰ the transcystic exploration is limited by the anatomy of the cystic duct, the number, size, and location of CBD stones, and the shortcomings of the choledochoscope. ¹⁰ The previous reports showed that LTCBDE was applicable in more than 85% of cases, ¹⁰ with a success rate of 85%. ¹¹

In this study, of 111 patients admitted for LTCBDE, 89 patients were treated successfully. The success rate was similar to a previous report. ¹¹ More important is that 34 patients (38.2%) undergoing successful LTCBDEs were discharged within 24 hours. This result provides the evidence that LTCBDE with discharge less than 24 hours is feasible and safe. The transcystic technology is the most important factor for discharge less than 24 hours.

It is important to identify risk factors to avoid the disappointment and disruption of an unexpected admission after the discharge. First, the number and size of the CBD stones are important factors. In this study, the number of CBD stones was no more than three, and the diameter was no more than 6 mm. It is reasonable that our criteria seem to be stricter than a previous report ¹⁰ because the risks of procedure-related complications such as bleeding and perforation will be increased significantly with repeated attempts and excessive use of the choledochoscope. ¹² At the same time, the patients treated with microincision of the cystic duct and lithotripsy may not leave the hospital within 24 hours after a longer surgery interval and possible procedure-related complications. ¹³ In the present study, only 1 patient could be discharged less than 24 hours when a microincision was used in the surgical procedure. Second, adequate pain relief and an effective protocol for control of nausea and vomiting are essential in a discharge less than 24 hours. ¹⁴ The routine use of prophylactic anti-emetic agents such as ondansetron can reduce the morbidity of nausea and vomiting. The use of postoperative intravenous and oral analgesics contributes a lot to the control of postoperative pain, which allows for early mobilization. Lastly, a multimodal approach involving appropriate preoperative assessment, education, and counseling, early postoperative oral intake, and early mobilization leads to a shorter postoperative length of hospital stay and earlier return to normal activity. ¹⁵ The elements within the multimodal approach have been based on best evidence by consensus opinion. ¹⁶ Above all, early postoperative oral intake and early mobilization promoted the recovery of gastrointestinal function. In our study, all the patients showed active bowel sounds and had flatus before discharge.

A 12-month follow-up presented a good short-term prognosis with no morbidity and mortality. Factors that contribute to this success may include the appropriate use of preoperative imaging and laboratory studies, extensive and careful dissection of the triangle of Calot structures, transcystic technology, and consistent follow-up of patients.

Conclusions

LTCBDE with discharge less than 24 hours is feasible and safe in selected patients with CBD stones of no more than three in number and no more than 6 mm in size. The benefit of the multimodal approach and LTCBDE may be synergistic, allowing a quick recovery of gastrointestinal function.