Fanelli Laparoscopic Endobiliary Stent Robert D. Fanelli, MD, FACS Assistant Professor of Surgery University of Massachusetts Medical School Director of Surgical Endoscopy Berkshire Medical Center

Laparoscopic Endobiliary Stent Placement Eliminates need for T-tubes, cystic duct catheters, external drains when Laparoscopic Transcystic Common Bile Duct Exploration (LTCBDE) or Laparoscopic Common Bile Duct Exploration (LCBDE) performed Eliminates need for LTCBDE or LCBDE for Common Bile Duct Stones (CBDS) Protects ductal closures, limits risks of bile leak

Laparoscopic Endobiliary Stent Placement Prevents complications associated with retained CBDS Virtually assures success of postoperative ERCP Necessary equipment inexpensive, readily available Suitable for use in ASCs as well as hospitals

Laparoscopic Endobiliary Stent Placement First described as adjunct to LCBDE, eliminating T-tubes 16 patients (1993-1995) 100% clearance CBDS by LTCBDE and LCBDE No bile leaks, complications 36 to 72 hour LOS Gersin, Fanelli.Surgical Endoscopy, vol.12 (4),April 1998 p. 301.

Laparoscopic Endobiliary Stent Placement Most surgeons rely on postoperative ERCP for CBDS Patients face risks of retained CBDS, pancreatitis, cholangitis, stump leak ERCP results vary based on volume High volume centers, > 95% selective cannulation rate Low volume centers, < 60% selective cannulation rate Average rates of selective cannulation, 80 to 85% 20% patients face reoperation, PTC, or referral for second ERCP for CBDS left at time of LC Conversion, T-tubes, drains deprive patients of low morbidity, quick recovery of LC T-tubes, drains require constant management, delay discharge

Laparoscopic Endobiliary Stent Placement Our current experience (SSAT Scientific Session, May 2000) 372 consecutive LC during 36 months, ending July 1999 Hasson cannula, three 5 mm upper abdominal ports, general anesthesia, CO2 insufflation, routine fluorocholangiography (FC) FC accomplished in all patients CBDS or suspicious FC identified in 48 (12.9%) No attempt made to clear CBDS, all patients treated with stents Stent placement added 9 to 26 minutes to LC operative time Cystic duct balloon dilation necessary in 14 (29.2%) Laparoscopic suturing, advanced skills were not utilized

Laparoscopic Endobiliary Stent Placement Hemorrhage, bile duct injury, duodenal perforation, sub-optimal stent placement, stent migration did not occur Longest f/u 46 months; original series, 80 month f/u 44 (92%) treated as outpatients 4 (8%) admitted overnight with average LOS 30 hours Indications for admission: PONV (2) surgery completed too late for discharge (1) weather too severe for safe discharge (1) Outpatient ERCP with ES 1 to 4 weeks later 100% successful for clearance of CBDS CBDS found in all patients -- no false positive FC No ERCP, stent related complications to date, including pancreatitis

Laparoscopic Endobiliary Stent Technique Routine FC via epigastric port Flexible tip cholangiogram catheter with three-way adapter Three-way adapter permits saline, contrast injection, and placement of wire guide

Laparoscopic Endobiliary Stent Technique 150 cm Tracer Hybrid® Wire Guide advanced through cholangiogram catheter Wire guide positioned across ampulla, past CBDS Cholangiogram catheter, removed over wire guide Finger occlusion of epigastric port prevents loss of CO2 Stent introducer port can be used if desired Cystic duct dilated if necessary

Laparoscopic Endobiliary Stent Technique Continuous fluoroscopy Stent assembly advanced over wire guide Position stent across ampulla Radiographic markers assure proper positioning Stent is fixed to delivery mechanism Stent location adjusted as needed prior to deployment Once position perfect, release safety to prepare for deployment

Laparoscopic Endobiliary Stent Technique Radiographic markers Marker 1 - distal tip Marker 2 - distal flange Marker 3 - proximal flange Marker 4 - proximal tip Markers signal deployment Markers 3, 2, and 1 pass through 4 during release After 3, 2, and 1 clear 4, stent is free of delivery system

Laparoscopic Endobiliary Stent Technique Stent successfully deployed Positioned across ampulla Contrast rapidly drains from CBD Cystic duct ligated Cholecystectomy completed Drains are not placed Patient is discharged when alert Placement of stent added 20 minutes to LC operative time

Laparoscopic Endobiliary Stent Technique ERCP 1 to 4 weeks postop Same admission feasible Various ERCP methods Snare removal of stent prior to cannulation, sphincterotomy Wire guide placed via stent prior to retrieval Precut sphincterotomy over stent Cannulate beside stent for sphincterotomy (preferred method)

Laparoscopic Endobiliary Stent Kit Stent and pusher assembly 150 cm Tracer® Hybrid Wire Guide Additional Components Introducer set 12 French cystic duct dilation balloon Cholangiogram catheter with three-way adapter, short wire

Conclusions There are numerous methods for treating CBDS during LC LCBDE is quick and highly successful, but requires refined laparoscopic suturing skills and carries risks of choledochotomy LTCBDE is time consuming, requires expensive equipment and endoscopic, fluoroscopic skills, but avoids choledochotomy Both employ external drains, T-tubes, or cystic duct catheters Laparoscopic stent placement is fast, involves minimal expense, does not require choledochotomy, eliminates external tubes and drains, and virtually assures success of postoperative ERCP

References Gersin KS, Fanelli RD. Laparoscopic Endobiliary Stenting as an Adjunct to Common Bile Duct Exploration. Surg Endosc 1998 Apr;12(4):301-304. Fanelli RD, Gersin KS. Laparoscopic Endobiliary Stenting: A Simplified Approach to the Management of Occult Common Bile Duct Stones. J Gastrointest Surg 2001 Jan/Feb; 5(1):74-80. Fanelli RD, Gersin KS, Mainella MT. Laparoscopic Endobiliary Stenting Significantly Improves Success of Postoperative ERCP in Low Volume Centers. Surg Endosc 2002 Mar;16(3):487-491. Wu JS, Soper NJ. Comparison of Laparoscopic Choledochotomy Closure Techniques. Surg Endosc 2002 Sep;16(9):1309-1313.