The management of patients with CBD stone and gallstone D. Chung

Introduction CBD stone present in 4-10% of those presenting with indication for lap cholecystectomy In era of open cholecystectomy, there was routine use of IOC +/- exploration (1 stage) With introduction of lap chole, there was move away from IOC and surgical management of CBD to 2 stage procedure with preop or postop ERCP

Introduction Reason: Lack of expertise for LECBD and reluctance to convert to open But, pre-op ERCP carries a significant false-positive rate Today, the advance of lap ECBD is increasingly reported to return the management of CBD stones to a one stage surgical procedure

Introduction Patient presented with CBD stone and gallstone Pre op ERCP + LC (2 stage approach) LC + IOC +/- LECBD (1 stage approach)

Introduction Two-staged approach ERCP & Laparoscopic cholecystectomy Heinennan PM et al, Ann Surg 1989 Wilson P et al, Lancet 1991 Surick B et al, Surg Endosc 1993 Mayer C et al, J Hepato Pancreat Surg 2002 Chan CM et al, ANZ J Surg 2005

Introduction One-staged approach Rhodes M et al, Lancet 1998 Laparoscopic cholecystectomy + laparoscopic exploration of common bile duct Rhodes M et al, Lancet 1998 Cuschieri A et al, Semin Laparosc Surg 2000 Lezoche E et al, Semin Laparosc Surg 2000 Nathanson LK et al, Ann Surg 2005 Paganini AM et al, Surg Endosc 2007

2 stage procedure (ERCP + lap cholecystectomy)

2 stage procedure Methods Pre-op ERCP + lap chole Lap chole + post op ERCP

2 stage procedure Advantage Avoid the need of T-tube Avoid the need of choledochotomy Avoid the complications of ECBD Need not to have expertise/operation set-up on LECBD

1 stage procedure (Lap cholecystectomy + IOC +/- LECBD)

1 stage procedure Two methods for LECBD 2) Choledochotomy 1) Transcystic duct exploration Preferred method for small CBD stones and small calibre CBD 2) Choledochotomy Multiple (>3), Large CBD stone (>1 cm ) Failed transcystic duct treatment CBD > or = 9 mm on cholangiogram

1 stage procedure Methods for closure of choledochotomy T-T closure Primary closure with stent Primary closure without stent

1 stage procedure Factors affecting the result of LECBD Approach to LECBD (Trans-cystic vs choledochotomy) Method for closure of choledochotomy Morbidity Bile leakage

1 stage procedure Advantage 1 stage procedure/1 admission Less costly Shorter hospital stay (with transcystic duct exploration) Avoid complications of ERCP Fail ERCP Preserve biliary sphincter Avoidance of risk of further stone migration from gallbladder to CBD while awaiting for lap chole

Evidence?

Evidence (Case series) Case series for LECBD (Most are transcystic duct exploration) 300 patients, 90% ductal clearance Martin IJ et al, Ann Surg 1998 129 consecutive patients, 92% ductal clearance Rhodes M et al, Br J Surg 1995 268 consecutive patients, 94.3% ductal clearance Pahanini AM et al, Ann Ital Chir 2000

Evidence (Randomised trial) Two stage approach VS LECBD (transcystic exploration or choledochotomy) 1) Rhodes M et al, Lancet 1998 (40 cases/arm) (LC + post op ERCP VS LECBD ) 2) Cuschieri A et al, Surg Endos 1999 (150 cases/arm) (Pre op ERCP + LC VS LECBD, multicenter trial ) Conclusion: Same ductal clearance rate, shorter hospital stay in LECBD group

Evidence (Randomised trial) Post op ERCP VS LECBD (Choledochotomy) Nathanson LK et al, Ann Surg 2005 372 cases of CBD stones, with 86 cases (23%) of failed transcystic duct exploration recruited to trial Choledochotomy 41 VS ERCP clearance 45 No difference in operative time, retained stone rate, overall morbidity and mortality

Evidence (Randomised trial) Management of CBD stones, laparoscopic versus endoscopic approach, a comparative study (pre-op ERCP + LC Vs LC + IOC +/- LECBD) Elbatanouny, A, Zeineldin, A British Journal of Surgery, Volume 93, September 2006 No significant difference in the clearance rate between 2 management options High rate of unnecessary ERCP in pre-op ERCP group (51.5%)

Evidence (meta-analysis) Meta-analysis of endoscopy and surgery versus surgery alone for CBD stone with the gallbladder in situ Clayton, E. S., Connor, S British Journal of Surgery Volume 93(10), October 2006

Evidence (meta-analysis) They identified 12 studies on Medline and ISI databases that met the inclusion criteria for data extraction (using keywords) Inclusion and exclusion criteria RCT in English language up to the end of March 2006 Review articles, retrospective analysis and abstracts were not included

Table 1                                                                                                                                                                                                                           

Evidence (results) Outcomes of 1357 patients were studied Successful duct clearance 77.6% in endoscopy + surgery group 79.8% lap CBD surgery group p=0.870 (n.s) Mortality 0.9% endoscopy + surgery group 0.5% lap CBD surgery group p=0.720 (n.s)

Evidence (results) Total morbidity rate 13.6% in endoscopy + surgery group 17.1% in lap CBD surgery group p=0.710 (n.s) Need of additional procedures after initial intervention 10.2% in endoscopy + surgery group 9.5% in lap CBD surgery group p=0.90 (n.s)

Evidence (results) No significant difference of successful duct clearance, mortality, total morbidity, major morbidity, need for additional procedures between the endoscopic and surgical groups

Primary closure Vs T-tube RCT on Primary Closure vs T-Tube Closure after choledochotomy Ha & Li et al, IHBPA 2004

Evidence (Primary closure Vs T-tube) Primary closure of the CBD is feasible and as safe as T tube insertion after laparoscopic choledochotomy for stone disease Similar morbidity, no mortality 1 bile leak(6.6%) in primary closure group and no bile leak in t-tube group Similar operative time ( 108.4 Vs 116.8 minutes, p=0.52) Shorter postoperative hospital stay (4 Vs 8 days, p<0.001)

Evidence No consensus to whether which approach is better Similar ductal clearance rate Similar morbidity and mortality

UCH experience for LECBD

UCH experience 2005-2006 Case number for LECBD Age Operation time 25 Age Mean 70.3 (47-87) Operation time Mean 212 mins (145-295) Stone clearance rate 96% (1 case with residual CBD stones)

UCH experience 2005-2006 Average CBD diameter (cm) Mean 1.4 (1-2.5) Number of CBD stones 1-12 Conversion rate 0% All performing choledochotomy Closure of choledochotomy 23 with placement of T-tube 2 with transcystic duct drain

UCH experience 2005-2006 Hospital stay Morbidity Mortality Mean= 12.8 days (9-17) Morbidity 1 case of retained stone 1/25 (4%) 1 case with distal CBD stricture 1/25 (4%) 1 case with retained transcystic duct drain require laparotomy and ERCP 1/25 (4%) Mortality 0%

UCH experience 2005-2006 Follow-up period 5-20 months

Conclusion Both 1 stage or 2 stage approaches have similar outcomes, and treatment should be determined by local resources and expertise

Our practice for LECBD LC + LECBD (1 stage approach) Good surgical risk CBD > 1cm 1 or more stones Especially case with large and multiple stones Fail ERCP

End