Cholecystolithiases and choledocholithiases combinedly

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1 DOI: /SUR/2015/40 Original Article Laparoscopic Cholecystectomy with Intraoperative Endoscopic Retrograde Cholangiopancreatography as a Combo Approach under Standardized Balanced General Anesthesia for the Management of Cholecysto-Choledocholithiasis: A Retrospective Study Sreejoy Patnaik 1, Rekha Das 2, Suchismita Nanda 3 1 Chief Consultant, Department of Minimal Access Surgery, Shanti Memorial Hospital Pvt. Ltd. Cuttack, Odisha, India, 2 Associate Professor & Head, Department of Aneasthesiology, Acharya Harihar Regional Cancer Centre, Cuttack, Odisha, India, 3 Intern, SCB Medical College and Hospital, Cuttack, Odisha, India Abstract Background: Cholecystolithiasis and choledocholithiasis combinedly known as or simply cholelithiases is of common occurrence with a worldwide incidence of about 10%. Though numerous treatment options are available but with the advent of minimally invasive techniques and endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic cholecystectomy (LC) with intraoperative ERCP (IO-ERCP) are the most recent researched technique so far. Objective: This study was done to assess the efficacy of LC with IO-ERCP for the management of cholecysto-choledocholithiases under protocolized balanced anesthesia. Methods: This retrospective study was conducted at a tertiary level hospital on 400 patients from 2008 to The patient selection was based on clinical presentations, laboratory investigations, and ultrasonography and magnetic resonance cholangiopancreatography imaging with positive evidence of gall bladder stones along with common bile duct (CBD) stones. Under general anesthesia as per standardized hospital protocol in all cases by conventional 4 port laparoscopic approach CBD was accessed, transcystically cannulated followed by IO-ERCP and completion of cholecystectomy. Results: Out of 400 patients, LC + IO-ERCP was successful in 304 cases. Neither the post-operative (PO) recovery was delayed nor was eventful. PO complications were also insignificant though we encountered a single case of post-ercp pancreatitis, but that was one of those cases where we failed to accomplish IO-ERCP, instead had to settle with post-lc ERCP in the same setting. Average operation time was ± 14.46, and the average duration of hospital stay was 2.15 ± Conclusion: The combo procedure of LC IO-ERCP was found to be very efficacious owing to less number of hospitalizations, shortened hospital stay, reduced chances of PO complication, decreased risks of anesthesia hence, both times saving, as well as cost effective with overall patient satisfaction. Keywords: Anesthesia, Cholecystolithiasis, Choledocholithiasis Access this article online Month of Submission : Month of Peer Review : Month of Acceptance : Month of Publishing : INTRODUCTION Cholecystolithiases and choledocholithiases combinedly known as cholecysto-choledocholithiases or simply cholelithiases is a very common occurrence with a worldwide incidence of about 10%. 1,2 Consequences, such as billiary peritonitis, empyema gall bladder (GB), Corresponding Author: Dr. Sreejoy Patnaik, Patnaik Colony, Thoria Sahi, Cuttack , Odisha, India. Phone: / sreejoypatnaik@gmail.com 23

2 cholangitis even carcinoma GB, are obvious in case of longstanding untreated cases of cholelithiases. 2-4 Though numerous treatment options are available, the advent of the minimally invasive technique of laparoscopic cholesystectomy (LC) has definitely outgrown the conventional open technique for GB stones (GBS) alone. However in the setting of GBS with common bile duct stones (CBDS), the conflict still remain whether perioperative endoscopic retrograde cholangiopancreatography (ERCP), i.e., either preceding or following LC is more effective or laparoscopic CBD exploration (LCBDE); or open exploration can give better results than former two. In the past few years, ERCP has definitely received more attention but this two-step dual endoscopic approach of LC and ERCP though more efficacious in terms of stone clearance and reduced mortality has the disadvantages of twice hospitalization, doubled risk of anesthesia, increased hospital bills particularly in cases of CBDS who are screened positive but are found negative on ERCP and most importantly any serious complication following one makes the other questionable. Keeping in view the duration of hospital stay and cost effectiveness; recent works have given way to the laparoendoscopic rendezvous operation by a combination of two procedures, i.e., LC-ERCP as a synchronous approach where ERCP is carried out during LC in a single step in the same setting under general anesthesia (GA). This not only minimizes the risk of perioperative anesthesia but also post-operative (PO) complications like pancreatitis and avoids the requirement of CBDE as well, by converting a two-step into a single step procedure. This study was carried out to assess the efficacy of LC intraoperative ERCP (IO-ERCP) as a synchronous approach for management of cholecysto-choledocholithiases under protocolized balanced anesthesia. MATERIALS AND METHODS This retrospective study was conducted at a tertiary level hospital between 2008 and 2014 on 400 patients who had GBS with either concomitant CBDS or with suspicious CBDs suggestive of same and were planned for LC with IO-ERCP. All patients were informed about the procedure, and written consent was obtained from each patient. All ERCPs and LCs were done by the same surgeon. Patient Selection All patients were screened on the basis of: Clinical presentations of pain abdomen and vomiting Clinical signs of tenderness in right upper quadrant abdomen, with/without clinical jaundice Laboratory investigations showing high bilirubin levels and/or raised alkaline phosphatases (ALP) and/or raised liver function test levels. Further confirmation was obtained by: Ultrasonography (USG) abdomen revealing gallstones along with suspicious CBDs and CBDs with diameter 8 mm, CBDS size <10 mm Magnetic resonance cholangiopancreatography (MRCP) showing evidence of CBDS. Patients with mild to moderate pancreatitis and cholangitis were subjected to pre-operative conservative treatment prior to the procedure. Pre-operative upper gastrointestinal (GI) endoscopy was carried out in all the patients to exclude any gastric outlet obstruction, peptic ulcer disease, or any upper GI pathology. Other exclusion criteria included: Age >80 years or <18 years; American Society of Anesthesiologists (ASA) score >3; Acute suppurative cholangitis (fever with chills, jaundice, pain right upper quadrant abdomen, shock, and central nervous system depression); Pancreatitis with serum amylase 3 times higher than normal; Pregnancy; Not suitable for endoscopic and laparoscopic surgery. Procedure Proper Anesthesia The entire procedure was performed under GA according to standardized hospital protocol. All cases received ceftriaxone 1 g, ondansetron 8 mg, and pantoprazole 40 mg intravenously (IV) 30 min prior to operation. 10 min before the operation, 2 mg IV midazolam was administered. All patient were preoxygenated with 100% O 2 for 5 min. Anesthesia was induced with 2 µg/kg IV fentanyl, 2 mg/kg IV propofol, and atracuriumbesylate 0.5 mg/kg IV following which intubation was done by cuffed endotracheal tube. Balanced anesthesia was maintained with sevoflurane 1-2%, propofol 2 mg/kg/h, and atracuriumbesylate 0.5 mg/kg/h. Ryles tube aspiration was done to remove gastric contents. Ventilation was done with 50% N 2 O/O 2, and tidal volume of 6-8 ml/kg and the respiration rate were adjusted to maintain a PaCO 2 of about mmhg. All patients were subjected to lung recruitment manoeuvre followed by positive end expiratory pressure (PEEP) adjusted to maintain oxygenation and blood pressure 24

3 Patnaik, et al.: Laparoscopic Cholecystectomy with Intraoperative for the Management of Cholecysto-Choledocholithiasis (BP). All cases were monitored for BP (non-invasive), electrocardiogram, pulse oximeter, airway pressure, end-tidal carbon dioxide (EtCO2), body temperature, peripheral neuromuscular function, and bis spectral index. 20 min before reversal 1000 mg acetaminophen infusion was given. To accomplish complete reversal after the operation, 2.5 mg/kg neostigmine, and 0.4 mg/kg glycopyrrolate were administered to all. the duodenum (Figure 6). With the patient in lateral decubitus position, a duodenoscope was introduced and advanced to the second part of the duodenum and the end of guidewire was snared and pulled out (Figure 7), following which the patient was brought back to supine At the end of surgical procedure, Ryles tube was removed. When patients were fully awake and showed adequate tidal ventilation with pressure support, were extubated, put on O2 mask and transferred to high dependency unit. In case of immediate PO pain fentanyl 25 mg IV, was given as rescue analgesia. Data were recorded to assess recovery of patients (from the time of discontinuation of anesthetic agents to recovery) which included: Early recovery (extubation, eye opening), late recovery (ambulation), early period (0-4 h), and late period (4-24 h), separately. Figure 2: Cholangiocatheter introduced through clip delivery into common bile duct Surgical Procedure The patient was placed on a C-ARM compatible table and after creating pneumoperitoneum, conventional 4 port LC was carried out. Initially, Calot s triangle was dissected and cystic artery was identified, clipped, and cut followed by cystic duct which was clipped high near the GB and a small nick was made distal to the clip (Figure 1), and a cholangio-cathter was introduced through it (Figure 2) followed by injection of 10 ml (50% diluted) and urograffin (Figure 3) and using C-ARM IO cholangiogram (IOC) was obtained. In cases of IOC confirmed CBDSs, IO-ERCP was carried out. A special technique was followed for CBD cannulation in which a guidewire (0.035 ) was passed through the cholangiocatheter (5 FR. ureteric catheter) by a transcystic approach through the CD (Figure 4) (Figure 5) and advanced through spinchter of oddi into Figure 3: Urograffin dye injected into clip delivery for intraoperative-cholangiogram Figure 1: Cystic artery and cystic duct clipped, and a nick made distal to clip on cd Figure 4: Guidewire introduced through clip delivery into common bile duct 25

4 Figure 5: C-arm image showing guidewire through common bile duct Figure 7: Snaring of guidewire Figure 8: Completion of cholecystectomy Figure 6: Guidewire coming out through sphincter position. Cannulation of CBD was done by directing the sphincterotome over the guidewire. After successful endoscopic sphincterotomy, saline irrigation was done for removal of small stones and for larger ones either balloon or dormia basket was used. In cases where cannulation could not be done, the stones were removed by dormia basket by conventional ERCP and sphincterotomy. A stent was given in all cases. Deflation of the GI tract was done to facilitate the dissection of GB and completion of LC (Figure 8). Complete stone removal was confirmed by a completion IOC. Data recorded included duration of operation (from the first incision for trocar insertion to closure of skin incision), time required for return of normal bowel activity (passage of flatus), immediate PO complications, and duration of hospital stay. Patients were followed up after 10 days and assessed on the basis of laboratory investigations, i.e., serum bilirubin and ALP levels and USG abdomen, then once in 3 months for a total period of 12 months and data regarding residual or recurrence of stones, as well as PO complications were recorded as well. RESULTS All 400 patients, 276 females and 124 males, presented with pain abdomen and vomiting and were positive for clinical signs of tenderness in right upper quadrant abdomen but only 227 patients had clinical jaundice. High bilirubin level was found in 341 patients with 231 having 3 g/dl and rest had values between 1 and 3 g/dl. Raised ALP was documented in 258 cases. 136 patients were diagnosed with cholangitis, whereas 15 had pancreatitis. They were managed conservatively, recovered within a week and were fit for surgery (Table 1). All 400 patients were positive for GBS on USG, but only 244 patients had dilated CBDs (dm 8 mm) of which stones were evident only in 217 cases, rest 27 though dilated did not show any evidence of stones. 156 patients had normal CBDs without any evidence of stones. The suspicious cases along with those with normal CBDs on USG were subjected to MRCP, which confirmed the presence of stones in all the cases. 26

5 LC was started in all cases but in 7 cases (1.75%) it was later converted to open method due to the presence of dense adhesions and distorted anatomy of Calot s triangle. In these cases, the cystic artery followed by cystic duct were ligated, and GB was dissected off. Open CBDE were done which successfully removed the calculi in 5 cases, whereas in rest 2 cases no stones were evident in the CBD. In rest 393 cases, LC was performed by standard 4 port technique. Moreover, in all these cases, IOC was obtained which showed the presence of stones in 356 cases (90.58%), whereas rest 37 were normal. Except these cases, IO-ERCP was attempted in all 356 cases but was successfully accomplished in only 335 cases (94.10%). In 238 cases, stones were removed by saline irrigation of the duct using cholangiocatheter, whereas rest 97cases required balloon or dormia basket. In 21 cases, CBD cannulation could not be done so ERCP was done in the same setting later by a conventional method after completion of LC of which 5 cases required papillotomy and stent placement. No IO complication was encountered except bleeding due to papillotomy in 2 cases and was managed by electrocauterization. IO BP was mmhg systolic and mmhg diastolic, pulse rate /min, respiratory rate 15-18/min, SpO %. The total duration of operation was ± Recovery (Table 2) PO recovery was immediate in 396 cases except 2 cases where recovery was delayed by 15 min to ½ h. One had the moderate restrictive pulmonary disease, and other was obese with body mass index 41. These two patients were kept on a ventilator. All patients were kept in recovery ward until they met the discharge criteria, i.e., conscious, well oriented, stable vital parameters, the absence of PO pain and PO nausea and vomiting (PONV). PO Complications (Table 2) PO course was uneventful in almost all patients except PO pain in 7 cases within 2 h of procedure that was managed by IV fentanyl 25 mg. PONV seen in 16 cases was treated by dexamethasone 8 mg IV. Three cases developed a mild fever on first PO day, which was managed with acetaminophen. Return of normal peristaltic activity was by PO day 2 in all cases that were evident by the passage of flatus. Discharge and Follow-up (Table 2) Average duration of hospitalization was 2.15 ± First follow-up was on the 10 th PO day where no one presented with any complaints. One patient presented with pancreatitis following 2 weeks of surgery but was Table 1: Preoperative and intraoperative data Total cases 400 Male: 124 Female: 276 Mean age 45.57±12.83 Patients with pancreatitis 15 Patients with cholangitis 136 Patients with GBS 400 Patients with dilated CBD on USG 244 Patients with CBDS on USG 217 Patients with dilated CBD but 27 without stones on USG Patients with normal CBD on USG 156 Patients with CBDS on MRCP 183 (156+27) (only those negative on USG) Cases converted to open 7 (2%) IOC done in cases 393 Patients with CBDS on IOC 356 Patients with normal IOC 37 IO ERCP attempted in cases 356 IO ERCP successful in cases 335 IO ERCP failure in cases 21 CBDS removal by saline irrigation 238 CBDS removal by balloon catheter and 97 dormia basket in IO ERCP Conventional ERCP done in 21 Total cases of successful LC with IO ERCP 335 Duration of operation ±14.56 GBS: Gall bladder stones, CBD: Common bile duct, USG: Ultrasonography, CBDS: Common bile duct stones, MRCP: Magnetic resonance cholangiopancreatography, IOC: Intraoperative cholangiogram, LC: Laparoscopic cholecystectomy Table 2: Post operative data PO recovery 100% Early recovery 398 Late recovery 2 Complications 29 IO complication (bleeding papillotomy) 2 Early complication 26 Fever 3 PONV 16 PO pain 7 Late complication (pancreatitis) 1 Duration of hospitalization 2.15±0.54 Post of follow up duration 1 year PONV: Post operative nausea and vomiting, PO: Post operative, IO: Intraoperative successfully managed conservatively. The stents were successfully removed during second follow-up after 3 months post-surgery. The total follow-up period was 1 year for each patient during which none showed any evidence of residual stones in CBDs or recurrences and it was confirmed by USG which also proved the patency of CBD in all cases. DISCUSSION Cholelithiases (cholecysto-choledocho-lithiases) once diagnosed should be treated, as long standing cases 27

6 can lead to a varied sequelaes ranging from simple pain abdomen to cholangitis and billiary pancreatitis and even carcinoma GB. 2-4 Though LCBDE has gained popularity in recent years but ERCP still remains the widely practiced technique for stone detection as well as extraction following an endoscopic sphincterotomy. Pre-operative ERCP though is highly effective in detection and management of CBDS, but more than 10% cases have been found negative for CBD stones on ERCP in spite of strict screening methods with an additional % chance of occurrence of post ERCP pancreatitis 5,6 this not only adds to patients hospital bills but also unnecessarily puts the patient at risk. Furthermore in cases with confirmed CBDS, it has a considerable failure rate with instances of residual stones and recurrences though no significant procedure related morbidity or mortality. 7 As studied by Cuschieri et al. 8,9 the efficiency of the laparoscopic single-step procedure (LC with simultaneous laparoscopic ductal stone clearance) was equal to that achieved with pre-operative ERCP and LC with the additional advantage of a shorter hospitalization and lower morbidity for the patients as obviously the later requires twice hospitalization. PO ERCP with stone retrieval by sphincterotomy though widely practiced 10 is good for surgeons inexperienced with LCBDE. However, again similar to pre-operative ERCP this also requires twice hospitalization and in cases of failure or complications it necessitates a third procedure. El Nakeeb et al. 11 performed a study on 80 patients with 74 cases being successfully managed by LC-ERCP by sequential method but in the same sitting, whereas Ghazal et al. 12 reported a success rate of 91.7% by managing 33 of 36 patients in whom IO-ERCP was attempted out of total 45 patients by the same approach. Our study had a similar result too with 304 patients being managed successfully by IO-ERCP, of 356 cases who underwent the procedure, out of total 400 patients selected. We used the same technique as Ghazal et al. 12 Enochsson et al. 13 and Iodice et al. 14 for cannulation of CBD and our results were similar to the previously cited studies. Cannulation of CBD was done by a special technique using a guidewire by transcystic approach which is a modified version of the rendez-vous technique described by Cavina et al. 15 we achieved a success rate of 94.1% though we failed to cannulate the CBD in 21/356 cases but were able to achieve a 100% ductal clearance like Ghazal et al. 12 whose success rate was 91.7%. Hong et al. 16 who compared LC-CBDE with LC IO-ERCP, reported the failure of CBD cannulation in 6 out of 93 patients in the later group. We did face problem while performing ERCP with the patient in a supine position, so we started with the patient in lateral decubitus position which made things a little easier and after successful placement of the scope the patients were repositioned and rest of the procedure was carried out successfully. According to Enochsson et al. 13 who reported an operating time of 192 ± 8.9 min for LC IO-ERCP, the main constraint was due to technical aspects and organizational problems related to proper installation and functioning of the endoscopic unit and C-ARM X-ray, which unnecessarily prolonged the duration of operation, rather than the procedure itself. We faced the same problem initially too, but we observed a progressive decrease in the duration over the subsequent years of study which was definitely a result of proper organization and improvement of technical skills. We performed the similar procedure as Ghazal et al. 12 who reported operation duration of 119 min ( min) during his study, whereas in our study the mean operation duration was ± min. El Nakeeb et al. 11 who performed the ERCP in the same sitting but after completion of LC reported average operation duration of 95 min. Moreover, we also performed IOC in all cases like Ghazal et al. 12 which further added to our operation duration too. Ghazal et al. 12 reported minor PO complications such as basal atelectasis, chest infections, and fever in 15 out of 45 cases (33.33%), whereas we had a post-ercp complication rate of 8.14% (29/356) with 2 cases of bleeding papillotomy which was managed using electrocauterization, 3 cases of mild fever, 7 cases of PO pain, and 16 cases of PONV all of which were managed conservatively. We did not encounter a single case of atelectasis probably owing to maintenance of a PEEP throughout the procedure. Meininger et al. 17 proved that PEEP definitely improves oxygenation during prolonged pneumoperitoneum, whereas Imberger et al. 18 found it to be beneficial in preventing PO pulmonary complications. We did encounter a single case of PO pancreatitis among those, we initially failed to cannulate the CBD and which was later managed by conventional ERCP and spinchterotomy but, it was managed conservatively too. We believed in rest of the cases it was due to the transcystic approach of CBD cannulation we followed, that the chances of pancreatitis were lowered considerably which has been already stated and proved in earlier studies. 12,15,19,20 No mortality was recorded. 28

7 All our patients were discharged by PO day 2-4 except the cases converted to open cholecystectomies that were discharged by day 5-7. The average hospital stay of patients under study was 2.15 ± 0.54 days. El Nakeeb et al. 11 reported a median hospital stay of 19 h (18-24), whereas Ghazal et al. 12 reported 2.55 (±0.89). Wright et al. 21 who compared pre-operative ERCP followed by LC with LC + IO-ERCP found out later was not associated with prolongation of the duration of hospitalization instead was more cost effective. But, Berthou et al. 19 reported a mean hospitalization of around 7 days in spite of high success rates in his study on LC-LCBDE. None of our patients reported with retained or recurrence of CBDS during a follow-up period of 1 year. CONCLUSION LC with IO-ERCP is definitely better than rest of the methods available for cholelithiases in terms of cost effectiveness particularly owing to single hospitalization, reduced hospital stay, decrease in health-related expenses, and minimalization of unnecessary procedures in setting of diagnostic uncertainty. However, the fact that it also saves the patient from unnecessary exposure to the risk of anesthesia by avoiding a second procedure is often unseen. However, this is an important aspect for the patients who either cannot afford or cannot sustain the risk for second time particularly those belonging to ASA 3. But on the other hand, it requires a lot of skill both in terms of technique as well as organization to overcome its only disadvantage of prolongation of operation duration. REFERENCES 1. Tazuma S. Gallstone disease: Epidemiology, pathogenesis, and classification of biliary stones (common bile duct and intrahepatic). 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8 with single-stage treatment with intraoperative ERCP for patients with symptomatic cholelithiasis with possible choledocholithiasis. Endoscopy 2006;38: Wright BE, Freeman ML, Cumming JK, Quickel RR, Mandal AK. Current management of common bile duct stones: Is there a role for laparoscopic cholecystectomy and intraoperative endoscopic retrograde cholangiopancreatography as a single-stage procedure? Surgery 2002;132: How to cite this article: Patnaik S, Das R, Nanda S. Laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiopancreatography as a combo approach under standardized balanced general anesthesia for the management of cholecystocholedocholithiasis: A retrospective study. IJSS Journal of Surgery 2015;1(6): Source of Support: Nil, Conflict of Interest: None declared. 30