One-Session Laparoscopic Management of Combined Common Bile Duct and Gallbladder Stones Versus Sequential ERCP Followed by Laparoscopic Cholecystectomy

Abstract

Aim:

This study aimed to evaluate the efficacy and safety of laparoscopic management of common bile duct (CBD) stones in a single session in comparison with two-session procedures including endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC). The most popular approach to treat CBD stones that were detected before LC is with ERCP followed by LC. This two-session approach has some disadvantages, which include spontaneous passage of stones found on magnetic resonance cholangiopancreatography while awaiting ERCP, the risk for CBD stone passage between ERCP and LC or during LC due to excessive gallbladder handling, and the need for multiple anesthesia sessions and hospital admissions within a short interval.

Patients and Methods:

A prospective outcome analysis was done for 150 patients with CBD stones treated either laparoscopically in a single session with either transcystic exploration (conducted in 23 cases) or CBD exploration (conducted in 46 cases) (Group I included 75 patients) or via two sessions using ERCP followed by cholecystectomy (Group II included 75 patients).

Results:

The rate of CBD clearance in Group I was 94.7%, whereas it was 97% in Group II. Group I is superior to Group II with regard to the operative time. There were no significant differences between the two groups regarding conversion to the open procedure, hospital stay, or postoperative complications.

Conclusions:

The single-session laparoscopic management of CBD stones is as safe and effective as the gold standard sequential ERCP followed by LC with nearly the same rate of success, hospital stay, and complications.

Introduction

From 10% to 18% of patients undergoing laparoscopic cholecystectomy (LC) for gallbladder stones have synchronous common bile duct (CBD) stones.^1,2 The frequency of asymptomatic choledocholithiasis in these patients varies between 5% and 15%, but this condition should be treated even if asymptomatic.^3,4

The most popular approach to treat CBD stones that were detected before LC is with endoscopic retrograde cholangiopancreatography (ERCP), followed by LC.⁵

This two-session approach has some disadvantages, including spontaneous passage of stones found at magnetic resonance cholangiopancreatography while awaiting ERCP, the risk for CBD stone passage between ERCP and LC or during LC due to excessive gallbladder handling, and the need for multiple anesthesia sessions and hospital admissions within a short interval.⁶

These potential problems can be avoided by using the single-session laparoscopic approach for managing CBD stones during LC by transcystic exploration (TCE) or laparoscopic CBD exploration (LCBDE) if TCE is not successful.⁷

This study aimed to determine the efficacy and safety of laparoscopic management of CBD stones in a single session in comparison with two-session procedures including ERCP.

Patients and Methods

This study included a prospective outcome analysis of 150 patients with gallbladder stones and confirmed CBD stones. The patients were divided into two groups: Group I included 75 patients managed by surgeons who had experience in single-session LCBDE either through TCE or through the choledochotomy approach, and Group II included 75 patients managed by surgeons who had experience in both ERCP and LC.

Both teams of surgeons agreed that any patient who met the inclusion criteria would be included in this study. Patient inclusion criteria were any patient with gallbladder stones who presented with jaundice, abnormal liver function tests, or ultrasonographic or magnetic resonance cholangiopancreatography evidence of a dilated CBD more than 8 mm with or without stone confirmation.⁸

Patients who had a history only of jaundice but no clinical, laboratory, or radiologic evidence suggesting CBD stones were not included in this study.

In Group I, intraoperative cholangiography was initially attempted in all patients. If a stone was detected, clearance was done via TCE, and if the procedure was unsuccessful or the stone was big, the surgeon shifted to choledochotomy and LCBDE using a Dormia basket and choledochoscopy.⁹ Transcystic biliary drains or a T-tube was placed in those patients who after exploration had multiple stones, patients with intraoperative fragmentation of the stones, or patients requiring repeated manipulation including passage of the Dormia basket through the papilla.

Group II patients were admitted first for ERCP; the procedure was done, and the patients were discharged on the same day unless there were complications. They were subsequently re-admitted after 2 weeks for LC after improvement of the liver profile and ultrasound examination.

Outcome was based on CBD clearance rate, operative time (the operative time was calculated from the start of anesthesia, and for Group II the operative time for both LC and ERCP were calculated together), complications, and total hospital stay.

Results

In the last 4 years, from January 2009 to January 2013, 150 patients who had concomitant CBD stones and gallbladder stones were enrolled in this study. They were divided into two groups: Group I included 75 patients managed by the single-session laparoscopic approach, and Group II included 75 patients managed by the sequential approach (ERCP followed by LC). Demographic data and clinical presentation of both groups are listed in Table 1, and there were no significant differences between the two groups.

Table 1.

Demographic Data and Clinical Presentation of Both Groups

Item	Group I (LCBD) (n=75)	Group II (ERCP+LC) (n=75)	P value
Age (years)			NS
Mean	47.1	39.07
Range (minimum–maximum)	34–72	23–64
Male:female (ratio)	26:49 (1:2)	27:48 (1:2)	NS
Clinical presentation			NS
Acute biliary pain with jaundice	65 (87%)	67 (89%)
Acute pancreatitis	6 (8%)	5 (7%)
Jaundice alone	4 (5%)	3 (4%)
Elevated liver enzymes	75 (100%)	75 (100%)
Dilated CBD on ultrasound or MRCP	69 (92%)	68 (91%)
Confirmed CBD stones	71 (94.7%)	72 (96%)
Total (n)	75	75

CBD, common bile duct; ERCP, endoscopic retrograde cholangiopancreatography; LCBD, laparoscopic common bile duct; MRCP, magnetic resonance cholangiopancreatography; NS, not significant.

Operative results

Operative results are shown in Table 2. Group I had a significantly lower total operative time in comparison with Group II. Group II had a higher rate of clearance of CBD stones than Group I, but the rates were not statistically different. Also, Group I had a nonsignificantly higher rate of conversion to the open procedure in comparison with Group II. Conversion in Group I occurred in 3 patients: in 1 patient it was due to bleeding, and in the other 2 patients it was due to a large CBD stone that could not be cleared through LCBDE. In Group II the conversion occurred in 1 patient due to a large stone that failed to be cleared by ERCP.

Table 2.

Operative Results of Both Groups

Operative results	Group I (LCBD) (n=75)	Group II (ERCP) (n=75)	P value
Operative time (minutes)	93±12.45	117±15.76	S
Clearance rate	69 (92%)	72 (96%)	NS
TCE	23 (30.7%)
LCBDE	46 (61.3%)
Conversion to open	3 (4%)	1 (1.3%)	NS
Negative for CBD stones	3 (4%)	2 (2.7%)	NS

CBD, common bile duct; ERCP, endoscopic retrograde cholangiopancreatography; LCBD, laparoscopic common bile duct; LCBDE, laparoscopic common bile duct exploration; NS, not significant; S, significant; TCE, transcystic exploration.

In Group I, TCE was tried first in 51 patients. It succeeded in 23 patients, and failure occurred in 28 patients due to large stones and inability to get clearance of the CBD so the surgeon shifted to choledochotomy, which was successful in 26 patients, and the other 2 patients were converted to the open procedure. In the remaining 21 patients, choledochotomy was done from the start due to large stones in the CBD; of these, 20 procedures were successful, and 1 patient was converted to the open procedure.

Regarding CBD drainage, in Group I, in TCE, no drain was inserted in 15 patients, and in the other 8 patients a transcystic drain was inserted. In LCBDE, direct closure was done in 18 patients, and a T-tube was inserted in 28 patients. In Group II, only 1 patient was converted to open CBD exploration and had T-tube drainage.

Postoperative complications

Postoperative complications are shown in Table 3. Group I had a higher nonsignificant rate of bile leakage in comparison with Group II. In Group I, 2 patients had a T-tube that slipped, and the patients developed bile leakage that was managed conservatively until it stopped; there was no need for another intervention for that complication. In contrast, Group II had a higher nonsignificant rate of post-ERCP cholangitis and acute pancreatitis. Both groups were comparable in length of hospital stay (Table 3).

Table 3.

Postoperative Complications in Both Groups

Complication	Group I (LCBD) (n=60)	Group II (ERCP) (n=60)	P value
Hospital stay (days)	2±0.53	2±0.57	NS
Bile leak	2 (2.7%)	0	NS
Cholangitis	2 (2.7%)	2 (2.7%)	NS
Perforation	0	0	NS
Postoperative acute pancreatitis	1 (1.3%)	4 (5.3%)	NS

ERCP, endoscopic retrograde cholangiopancreatography; LCBD, laparoscopic common bile duct; NS, not significant.

Discussion

Since the introduction of LC in 1991, the standard treatment for CBD stones has been endoscopic sphincterotomy and endoscopic extraction of these stones, followed by LC.¹⁰

With refinements in laparoscopic techniques and experience, many centers have started performing LCBDE with acceptable results and complications.¹¹

The results in this study are comparable between the two groups as there was no significant difference between them regarding success rate in clearance of CBD stones, rate of conversion to the open procedure, hospital stay, and postoperative complications, and the only significant difference was in operative time, which was significantly lower in Group I. This may be attributed to admission of the patient to the operating room twice and two different anesthesia and surgical sessions that required preparation in Group II.

The majority of CBD clearance in Group I in this study involved direct choledochotomy rather than TCE of CBD, in contrast to the literature.^10,12 This is because the stone bulk in our patients is large, and it is not feasible to achieve complete clearance of the CBD by TCE. In this study choledochotomy was successful in 46 patients, and TCE was successful in 23 patients.

The results in this study are comparable with those of the study done by Hong et al.,¹¹ who compared LC combined with intraoperative endoscopic sphincterotomy versus LC combined with LCBDE. In their study, 234 patients were divided into an LC combined with LCBDE group (141 cases) and an LC combined with intraoperative endoscopic sphincterotomy group (93 cases). There was no difference between the two groups in terms of surgical time, surgical success rate, number of stone extractions, postoperative complications, retained CBD stones, and postoperative length of stay. It was concluded that both procedures were shown to be safe, effective, minimally invasive treatments for concomitant gallbladder and CBD stones.

Also, in two separate studies done by Costi et al.² and Bansal et al.¹³ comparing a single-stage laparoscopic approach with sequential treatment, no difference emerged concerning early and late complications, mortality, or laparotomies needed to accomplish cholecystectomy and CBD clearance. The postoperative hospital stay was shorter in the single-stage group.

Conclusions

The single-session laparoscopic management of CBD stones is as safe and effective as the gold standard sequential ERCP followed by LC with the nearly same rate of success, hospital stay, and complications and avoids the need for multiple anesthesia sessions and hospital admissions within a short interval.

Footnotes

Disclosure Statement

No competing financial interests exist.

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