Pamela Youde Nethersole Eastern Hospital Management of Concomitant Gallbladder and Common Bile Duct Stones Joint Hospital Surgical Grand Round 19th October 2013 Dr. Wong Chun Lam Pamela Youde Nethersole Eastern Hospital Hong Kong SAR

Background 10-18% of patients with gallbladder stones harbor common bile duct stones Before development of laparoscopy Pre-operative endoscopic retrograde cholangiopancreatography (ERCP) with open cholecystectomy Open cholecystectomy with exploration of common bile duct Open cholecystectomy with post-operative ERCP

With advancement in laparoscopic surgery Laparoscopic cholecystectomy (LC) + CBD exploration (LCBDE) LC + Intra-operative ERCP LC + Open cholecystectomy Pre-operative ERCP + LC LC + Post-operative ERCP

Factors affecting choice Patient’s general condition Previous operation Stone’s characteristics (size, number, location) Anatomy of biliary tree Timing of discovery of CBD stones Facilities Expertise in laparoscopic surgery / ERCP

Pre-operative ERCP + LC Patient presenting with obstructive jaundice / cholangitis / severe pancreatitis ERCP  initial therapeutic procedure Followed by lap. cholecystectomy after condition improved Advantage Technical skill not demanding Minimizes operation time Disadvantage Two-stage procedure Possible septic complications between two procedures

LC + Laparoscopic CBD exploration (LCBDE) Failed endoscopic removal of CBD stones CBD stones difficult for endoscopic removal History of gastrectomy Multiple CBD stones Large CBD stones Advantage: Single-stage procedure Disadvantage: Technically demanding Risks of bile duct complications

LCBDE (Transcystic approach) Cystic duct is dilated Balloon / flexible basket / choledochoscope through cystic duct to CBD for stone retrieval Cystic duct closed with clips / sutures Contraindications Biliary stones proximal to cystic duct junction Small cystic duct Spiral shape of cystic duct Large stones Multiple stones

LCBDE (Choledochotomy) Longitudinal incision at anterior surface of CBD Instruments inserted directly CBD to extract stones Electrohydraulic / Laser lithotripsy Closure of CBD with sutures +/- placement of T-tube Indications Large stones Multiple stones Ductal stones proximal to cystic duct junction Disadvantage Technically demanding Risk of bile duct stricture and bile leak Contraindications CBD not dilated

On-table ERCP Rendezvous technique Advantage: Disadvantage: Guidewire inserted through cystic duct into duodenum Guidewire caught by duodenoscope Papillotome inserted over guidewire to facilitate CBD cannulation Advantage: Single-stage procedure 100% cannulation rate Disadvantage: Supine positioning may cause ERCP more difficult Longer operation time Stones may not be able to clear in one go Requires ERCP endoscopist / staff / equipments in operating theatre

Post-operative ERCP CBD stones noted intra-operatively Advantage Non dilated CBD No expertise in LCBDE Advantage Technically not demanding Disadvantage Two-stage procedure Need another operation (CBD exploration) in case of failure Increased hospital stay and cost

Current Evidence

Pre-op ERCP + LC vs LC + LCBDE 112 patients with radiological / biochemical evidence of possible CBD stones Pre-op ERCP + LC (n=55) LC + IOC +/- LCBDE (n=57) P-value CBD stone detected 31 17 0.007 CBD stone cleared 30 (98%) 15 (88%) 0.28 Morbidity 9.1% 10.5% >0.99 Mortality 0% Hospital stay 6.6 days 5.3 days <0.05 Rogers SJ et al. Arch Surg 2010; 145(1):28-33. (US)

Pre-op ERCP + LC vs LC + LCBDE 30 patients with GB stones and CBD stones confirmed on EUS / MRCP Pre-op ERCP + LC (n=15) LC + LCBDE P-value CBD clearance 86.7% 93.5% >0.05 Morbidity 15.3% 13.3% Mortality 0% Hospital stay 4 days 4.2 days Bansal VK et al. Surg Endosc 2010; 24: 1986-1989. (India)

Pre-op ERCP + LC vs LC + on-table ERCP 91 patients with GB and CBD stones diagnosed by MRCP Pre-op ERCP + LC LC + on-table ERCP P-value CBD clearance 80% 95.6% >0.05 Pancreatitis 0% 2.2% Morbidity 8.8% 6.5% Mean hospital stay 8 days 4.3 days <0.0001 Total cost £3834 £2829 <0.05 Morino M et al. Ann Surg 2006; 244: 889-893. (Italy)

Pre-op ERCP + LC vs LC + on-table ERCP P-value CBD clearance 96.6% 90.2% >0.05 Pancreatitis 12.7% 1.7% <0.05 Morbidity 23% 8.5% Mean hospital stay 8 days 5 days Total cost £2708 £2414 Rabago LR et al. Endoscopy 2006; 38: 779-786. (Spain)

LC + LCBDE vs post-op ERCP 80 patients noted to have CBD stones in operative cholangiogram during lap. cholecystectomy LC + LCBDE (n=40) LC + Post-op ERCP P-value Stone clearance 30 (75%) >0.05 Morbidity (17.5%) (15%) Mortality Hospital stay 1 days 3.5 days <0.05 Rhodes et al. Lancet 1998; 351: 159-161. (UK)

LC + LCBDE vs post-op ERCP 372 patients undergoing LC for symptomatic gallstones noted to have CBD stones by transcystic cholangiography 286 patients achieved CBD clearance with transcystic approach Remaining 86 patients in which transcystic clearance was failed LC + LCBDE (n=41) LC + Post-op ERCP (n=45) P-value Stone clearance 40 (97.6%) 43 (95.6%) >0.05 Severe pancreatitis 1 (2.4%) 1 (2.2%) Morbidity 7 (17%) 6 (13%) Hospital stay 6.6 days 7.4 days Nathanson LK et al. Ann Surg 2005; 242: 188-192. (Australia)

Conclusion Comparable stone clearance rate and morbidity between all options Single-stage procedures Potential benefit of reducing hospital stay / cost Technically demanding Depends on patient conditions, stone characteristics, facilities and expertise