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1 CMYK19 Original Article Antegrade common bile duct (CBD) stenting after laparoscopic CBD exploration Samik Kumar Bandyopadhyay, Shashi Khanna, Bimalendu Sen, Om Tantia Department of Minimal Access Surgery, ILS Multispeciality Clinic, Salt Lake City, Kolkata, India Address for correspondence: Om Tantia, Department of Minimal Access Surgery, ILS Multispeciality Clinic, DD-6, Sector I, Salt Lake City, Kolkata , India. ils@gptgroup.co.in Abstract may be performed safely in expert hands without mortality and with negligible morbidity. Laparoscopic common bile duct exploration (LCBDE) has been found to be a safe, efficient and Key words: Antegrade stenting, choledochoduodenostomy, cost-effective treatment for choledocholithiasis. choledocholithiasis, laparoscopic common bile duct Following LCBDE, the clearance may be exploration, T-tube drainage ascertained by a cholangiogram or choledochoscopy. The common bile duct (CBD) may be closed primarily with or without a stent in Laparoscopic common bile duct exploration (LCBDE) situ or may be drained by means of a T-tube or a has been found to be a safe, efficient and cost-effective biliary enteric anastomosis. Materials and treatment for choledocholithiasis. [1,2] Up to 16% of Methods: In our series of 464 patients of patients with gallstone disease may have concurrent choledocholithiasis, 100 patients underwent closure of the CBD with an indwelling antegrade stent choledocholithiasis. [3-5] In a conventional open following LCBDE. LCBDE was performed by direct common bile duct (CBD) exploration, a clearance rate massage of CBD, saline lavage, direct pickup with of more than 90% was accepted as a standard of choledocholithotomy forceps or by basketing. care. [6] However, this implied that nearly 10% of these Fragmentation of impacted stones in situ was patients had a missed or a slipped stone and were performed in a few patients. Completion choledochoscopy was performed by means of a liable to undergo re-exploration. pediatric bronchoscope. A 10-cm, 7 Fr. double-flap biliary stent was placed in situ after LCBDE. Endoscopic CBD clearance following an endoscopic Results: There was no mortality in the series.there sphincterotomy gained popularity as a means to was no conversion either. The median duration of tackle choledocholithiasis with cholelithiasis. The the operation was 75 min.the mean postoperative hospital stay was 3.5 days. One patient had a minor introduction of laparoscopy in treating postoperative biliary leak. One patient had a right choledocholithiasis as a single stage treatment raised sub-hepatic collection. Four patients developed postoperative port infection. The stents were removed endoscopically after 4 weeks. Sixty-eight an important issue - how to choose the treatment for each particular patient. patients could be followed up till 1 year. There has been no incidence of residual disease and the We started performing CBD explorations in As patients on follow-up are asymptomatic. per our institutional protocol, we have used different Conclusion: In our experience, a single stage modalities to clear the CBD. However, due to the laparoscopic treatment of cholelithiasis with limitations involved in transcystic LCBDE, we have choledocholithiasis is a safe, viable and costeffective option. Closure of the CBD over an always performed LCBDE through a properly antegrade stent is a feasible option but requires performed choledochotomy. Hereby, we present our advanced skills in minimal access surgical experience with antegrade stenting of the common techniques, especially endosuturing.the procedure bile duct following LCBDE. 19 Journal of Minimal Access Surgery January-March 2007 Volume 3 Issue 1

2 20 CMYK MATERIALS AND METHODS A retrospective study of the patients treated for choledocholithiasis in the period between August 2000 and March 2005 was performed. The specially designed departmental software was utilized to retrieve the data. A single surgical team at our institute performed 5,043 laparoscopic cholecystectomies between August 2000 and March In the same period, 464 patients with choledocholithiasis were treated at the institute, of whom 22 patients had a primary or a slipped / missed CBD stone following cholecystectomy. patients underwent a successful clearance of CBD stones [Table 2]. Sixteen patients with a negative ERCP underwent laparoscopic cholecystectomy (LC) only. There were 38 ERCP failures due to various reasons [Table 2]. These patients subsequently underwent LCBDE. Of the 22 patients with post-cholecystectomy CBD stones, 7 were taken up for LCBDE directly; whereas 3 others who had a failed ERCP extraction also underwent LCBDE. As per the institutional protocol, patients with severe pancreatitis were initially treated conservatively and resuscitated before being subjected to any interventional operation. Patients with pancreatitis but otherwise stable (Ranson s score <4) were treated as per the The series included 318 female and 116 male patients. institutional protocol. The majority of the patients (210) belonged to the age group between 40 and 60 years, followed by the In patients with a strong suspicion of CBD stones on age groups years (133) and years (107). clinical and biochemical indicators, not otherwise Only 14 patients were aged less than 14 years. The documented by preoperative sonogram (in most of the commonest presentation was abdominal pain, either cases) or magnetic resonance cholangiopancreatography in the epigastrium or the right hypochondrium (MRCP) (in a selected few), we prefer to perform a per (50.5%). A history of jaundice or icterus at presentation operative cholangiogram (POC). MRCP was done only was found in 35.19% of the patients, whereas 21% of in selected patients in our series due to financial patients had a history of prior hospitalization due to constraints. In 69 patients who underwent POC, 52 acute pain in abdomen and a conservative patients were found to have a CBD stone and underwent management. There is a fixed institutional protocol subsequent LCBDE with LC. that is implemented while treating patients with choledocholithiasis [Table 1]. LCBDE was performed in 181 patients, of which LC with LCBDE was done in 171 patients, while 10 Out of 464 patients of confirmed choledocholithiasis, patients of primary / missed CBD calculus underwent 316 patients were referred to endoscopic retrograde only LCBDE. Post-exploratory T-tube drainage of CBD cholangiopancreatography (ERCP), of whom 262 was done in 18 patients, primary closure of CBD without any internal drainage was done in 4 patients Table 1: Institutional protocol for management of while laparoscopic choledocho-enteric anastomosis cholelithiasis with choledocholithiasis was performed in 59 patients Institutional protocol for management of cholelithiasis with choledocholithiasis Table 2: Break up endoscopic retrograde cholangiopancreatography group Patients subjected to ERCP n = 316 (68.1%) Pre-op ERCP followed by LC LC with LCBDE Documented CBD calculus in undilatedcbd<10mm Cholangitis H/O Biliary Pancreatitis Suspicion of malignancy Multiple large calculi CBD DilatedCBD>10mm Intra-hepatic calculi ERCP failures Economic reasons Successful CBD clearance 262 (83%) Negative ERCE 16 (5.19%) ERCP failure 38 (21%) Multiple large calculi: 15 (39.4%) Failure to cannulate: 9 (23.6%) Failure to extract: 7 (18.4) Seconday Primary Peri-ampullary diverticulum: %) Broken dormia: 1 Journal of Minimal Access Surgery January-March 2007 Volume 3 Issue 1 2 0

3 CMYK21 (choledochoduodenostomy - 52 and choledochojejunostomy - 7). One hundred patients had undergone post-exploratory antegrade biliary stenting with closure of CBD on the stent [Table 3]. Of the 18 patients with T-tube drainage, 1 patient had bouts of recurrent cholangitis and most patients were clearly unhappy at having a tube from their body. Patients from a rural setting were clearly unwilling to go home with a tube, resulting in their requiring a prolonged hospital stay. These feedbacks played an important role in offering the patients the benefit of stented choledochorrhaphy. A standard 4-port approach was utilized. An optional fifth port (5 mm) was introduced midway between the right hypochondrial and umbilical ports to allow the introduction of a catheter for lavage or suction of the CBD. Cincinnati, USA) was placed towards the gallbladder and a nick was created on the cystic duct (CD), which was then cannulated with a 4-5 Fr. ureteric catheter (which had been pre-primed with normal saline to expel possible air bubbles). A clip was then applied on the CD to prevent leakage of contrast material. Ports were withdrawn, the abdomen was deflated and a cholangiogram was obtained with a Digital C arm Fluoroscopy (real time imaging). If a radiolucent shadow was noted, the position of the patient was altered to rule out an air bubble and the entry of contrast material into the duodenum was noted. On the basis of a positive POC, 52 patients underwent simultaneous LCBDE with LC. The duodenum was then kocherized up to the lateral border of the inferior vena cava to straighten out the CBD. The position of the CBD was confirmed by needle aspiration with a 24 G needle. The CBD was A standard cholecystectomy was performed then opened longitudinally between 3-0 silk. We have laparoscopically, but the cystic duct was not divided avoided transcystic LCBDE because of its inherent and also the gallbladder was not lifted from the liver limitations [Table 4]. bed. Mirizzi syndrome necessitating transaction of the gallbladder at the neck was encountered in nine In most of the patients, the stones were recovered patients. The remnant cuff was subsequently sutured by spontaneous extrusion on choledochotomy or by with 3-0 vicryl sutures. Cholecysto-enteric fistula was gentle milking with the instruments [Figure 1]. A 12 found in five patients (cholecystoduodenal - 4, Fr. Ryles tube (with its tip cut off) introduced through cholecystocolic - 1). The fistulas were isolated during the accessory 5-mm port was used to perform operation using a combination of sharp and blunt proximal and distal lavage of the common bile duct dissection and fistulectomy was performed with and help in extrusion of the stones. Stones were also scissors. The ensuing rent in the bowel was closed removed by means of a Dormia basket [Figure 2] or a with interrupted 3-0 vicryl sutures in two layers. Fogarty catheter under direct flexible choledochoscopic control. In a few patients, curved Per-operative cholangiogram was performed in 69 Desjardines choledocholithotomy forceps were patients. In these patients, following the introduced directly through the epigastric wound skeletonization of the cystic duct, a medium large after removal of the 10-mm epigastric port, in order clip (Ligaclip LT 300; Ethicon Endosurgery Inc, to clear the distal CBD. Table 3: Laparoscopic common bile duct exploration flow chart 21 Journal of Minimal Access Surgery January-March 2007 Volume 3 Issue 1

4 22 CMYK Table 4: Limitations, contraindications and complications of trans-cystic laparoscopic common bile duct exploration [7] Limitations: Small cystic duct diameter Low common bile duct cystic duct junction Obstructive valves in cystic duct Contraindications: Large multiple stones in common bile duct Stones in upper common bile duct Complications Common bile duct perforation Common bile duct avulsion cleared by means of forceful saline lavage. Confirmation of CBD clearance was done by postexploratory cholangiogram in 32 patients and choledochoscopy in 130 patients. Completion choledochoscopy was performed by means of a pediatric bronchoscope (Pentex FB-15P). Following this, a guide wire was then passed through the side channel of the bronchoscope over which a 7 Fr, 10 cm double-flap biliary stent was guided into the CBD up to the duodenum across the sphincter. The CBD was then closed by interrupted 3-0 vicryl sutures. Figure 1: Stone being delivered from CBD by gentle milking The cystic duct was then divided and the gallbladder was then lifted up from the liver bed and removed with the extracted stones in an endobag. Hemostasis was secured, a subhepatic drain was placed and the abdomen was deflated. RESULTS In the time period between August 2000 and March 2005, 100 patients underwent antegrade CBD stenting following LCBDE at our institution. The median duration of the operation was 75 min (55-155) min. Early oral intake and early ambulation was encouraged. Most of the patients were allowed to have liquids on the day of the operation and were ambulatory the next day. The mean postoperative hospital stay was 3.5 days (2-7 days). The intraabdominal subhepatic drains were removed once the output was less than 20 ml/day. By the third postoperative day, all but one patient had their drains removed. The patients with cholecysto-enteric fistula were allowed oral intake from the third postoperative day. Figure 2: Stone being delivered from CBD by a Dormia basket In patients with impacted stones in the CBD or common hepatic duct, a rigid ureteroscope introduced through an additional subxiphoid port (5 mm) for lower CBD or through the umbilical port for upper CBD, was used to fragment the stones by means of intracorporeal contact lithotripsy using a pneumatic lithotripter. The sediments were then There was no conversion in the series nor was there any mortality. After discharge, the patients were followed up at 1week, then monthly for 2 months and subsequently were asked to come for annual checkups for 2 years. The stent was removed endoscopically after 4 weeks at the first monthly visit. One patient had a minor biliary leak via the drainage tube, which stopped spontaneously on the fifth postoperative day and the tube could be removed Journal of Minimal Access Surgery January-March 2007 Volume 3 Issue 1 2 2

5 CMYK23 on the sixth postoperative day. Four patients developed port infection, which was controlled with antibiotics. A male patient who had a cholecystoduodenal fistula reported with fever after 2 weeks. Abdominal ultrasonogram showed a rightsided subhepatic collection, which yielded pus on guided aspiration. The collection was fully aspirated and the patient was admitted and treated conservatively with parenteral antibiotics. He had an otherwise uneventful recovery. cost-effective procedure than endoscopic clearance of the CBD. [10-12] Following the principles of open surgery, a surgeon has multiple options regarding the management of choledochotomy following LCBDE: Primary closure with / without an antegrade biliary stent [8,13-15] Closure over a T-tube [15-19] Bilio-enteric bypass (in indicated patients) [19,20] Prolonged ileus (till the fourth postoperative day) In this study period of LCBDE, it was nearly 2 years associated with hypokalemia was encountered in a before we attempted closure of choledochotomy with 71-year-old diabetic male patient. The ileus resolved an antegrade biliary stent. This happened once we on the fifth postoperative day and the patient was started performing completion choledochoscopy for discharged the next day. confirmation of CBD clearance. Post-exploratory cholangiogram was found to be technically The stents were removed endoscopically after 4 weeks cumbersome, with false interpretation due to leaks in all the patients. The follow-up protocol at our and air bubbles. institute entails postoperative checkups at the end of the first and the fourth week. Similar protocol of In the initial period, a CBD dilated beyond 1.5 cm removal of stent at 4 weeks after operation was was treated with a choledocho-enteric anastomosis, followed by Isla Griniatos and Wan at Ealing Hospital, while T-tube drainage was performed in the undilated London. [7] Selectively, ERCP was performed at stent ones. The presence of a T-tube is associated with a removal to assess the status of the CBD. One patient few known disadvantages - patient discomfort, an had transient cholangitis following stent removal, increased hospital stay, delayed recovery, tube which was controlled with parenteral antibiotics. All displacement / dislodging, infection and but 17 patients were followed up regularly till the fragmentation, to name a few. [21] This led us to think third postoperative month. Follow-up till the first year about offering alternative options to our patients. could be completed in 68 patients. There has been Our experiences at transcystic exploration were also no incidence of residual disease and all the patients not encouraging. In two patients in whom we who were in regular follow-up have been attempted a transcystic CBD exploration, a change asymptomatic. of operative approach to choledochotomy was precipitated as we failed to achieve CBD clearance DISCUSSION through cystic duct. The ease of direct CBD exploration and our failure with transcystic LCBDE is now a frequently performed operation by approaches led us to follow a protocol of laparoscopic surgeons experienced in advanced minimal access CBD exploration as has been described in this article. surgeries. LC with LCBDE could be performed as a This is as true for laparoscopic surgery as it is for single stage procedure in a large series. [8] LCBDE has open surgery. [22-24] Hence we decided to try primary been shown to be as effective as endoscopic stone closure of the CBD following LCBDE in our patients, removal with lesser procedural time and shorter our decision being based on available encouraging hospital stay. [9] This allows the preservation of the reports. [8,25-27] Unfortunately, two out of the four functions of sphincter of Oddi and thus does away patients in whom we attempted primary closure of with the risks of cholangitis, pancreatitis and, as a the CBD developed bilioma in the immediate long-term possibility, malignancy, etc, following a postoperative period and re-laparoscopy had to be sphincterotomy. It has also been shown to be a more done, where leak was found from the 23 Journal of Minimal Access Surgery January-March 2007 Volume 3 Issue 1

6 24 CMYK choledochotomy site in both the patients and was subsequently closed over a T-tube. This experience prevented us from attempting any other primary closure of unstented CBD. Report of an animal study published earlier [28] led us to conceptualize closure of the CBD over an antegrade biliary stent. The first report of laparoscopic primary closure of the CBD had come from Lange V and his team. [29] We had started performing choledochoscopies followed by antegrade biliary stenting by then. The initial experiences (8 patients Table 5: Complication following antegrade stenting after laparoscopic common bile duct exploration Port infection 4 Minor biliary leak 1 Subhepatic collection 1 Prolonged ileus 1 Cholangitis after stent removal 1 Haematoma (umbilical port) 1 Total 9 CONCLUSION A single stage laparoscopic treatment of cholelithiasis with choledocholithiasis has been found to be safe, 5 female and 3 male) over a 3-month period were viable and cost-effective. Closure of the CBD over an encouraging and we persisted with the technique. antegrade stent after LCBDE is a feasible option but requires advanced skills in minimal access surgical techniques, especially endosuturing. Endoscopic removal of the stent after a safe interval of 4 weeks does not result in significantly added morbidity and cost of the treatment procedure. Recently, modified plastic biliary stents (after removing the proximal flap) have also been used [30] and there have been more reports describing the success of this procedure, [31,32] which had been already found to be a preferred technique in animal experiments as well. [33] We however do not remove REFERENCES the proximal flap for the fear of premature expulsion of the stent. 1. Lezoche E, Paganimiam AM. Single stage laparoscopic treatment of gallstones and common bile duct stones in 120 unselected consecutive patients. Surg Endosc 1995;9: The experience of our first hundred patients where 2. Urbach DR. Khajanchee YS, Jobe BA, Standage BA, Hansen PD, an antegrade biliary stent had been used as an adjunct to CBD closure has been encouraging. There has been no conversion or mortality. The incidence and complication has been minimal [Table 5]. Swanstrom LL. Cost-effective management of common bile duct stones: A decision analysis of the use of endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography and laparoscopic bile duct exploration. Surg Endosc 2001;15: A prospective analysis of 1518 laparoscopic cholecystectomies. The Southern Surgeons Club. N Engl J Med 1991;324: In these days of evidence-based incidence, we have 4. Curet MJ, Pitcher DE, Marit DT, Zucko KA. Laparoscopic antegrade sphincterotomy: A new technique for the management of complex instituted a protocol according to which our patients choledocholithiasis. Ann Surg 1995;221: having choledocholithiasis with cholelithiasis are 5. Rojas-Ortega S, Arizpe-Bravo D, Marin lopez ER, Cesin-Sanchez R, treated. The principles of the protocol include the Roman GR, Gomec C. Transcystic common bile duct exploration in the management of patients with choledocholithiasis. J following: Gastrointest Surg 2003;7: Defined indications for preoperative ERCP [Table 6. Petelin JB. Laparoscopic common bile duct exploration. Surg Endosc 2003;17: ] 7. Isla AM, Griniatsos J, Wan A. A technical for safe placement of a Defined indications for LC with LCBDE [Table 1] biliary endoprosthesis after laparoscopic choledochotomy. J LCBDE performed via choledochotomy directly. Laparoendosc Adv Surg Tech A 2002;12: Cuschieri A, Lezoche E, Morino M, Croce E, Lacy A, Toouli J, et al. Transcystic LCBDE was avoided because of E.A.E.S. multicenter prospective randomized trial comparing twostage vs single-stage management of patients with gallstone inherent limitations and possible contraindications / complications [Table 4] disease and ductal calculi. Surg Endosc 1999;13: Decker G, Borie F, Millat B, Berthou JC, Deleuze A, Drouard F, et al. Choledocho-enteric anastomosis is performed after One hundred laparoscopic choledochotomies with primary LCBDE if CBD diameter is >1.5 cm closure of the common bile duct. Surg Endosc 2003;17:12-8. All other patients undergo closure of 10. Phillips EH, Lieberman M, Carrok BJ, Fallas MJ, Rosenthal RJ, Hiatt JR. Bile duct stones in the laparoscopic era: Is pre-operative choledochotomy with an antegrade biliary stent, sphincterotomy necessary? Arch Surg 1995;130: which is removed endoscopically after 4 weeks. 11. Heili MJ, Wintz NK, Fowler DL. Choledocholithiasis: Endoscopic Journal of Minimal Access Surgery January-March 2007 Volume 3 Issue 1 2 4

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