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

2. 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

3. 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

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

5. 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

6. 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

7. 2 stage procedure (ERCP + lap cholecystectomy)

8. 2 stage procedure Methods Pre-op ERCP + lap chole
Lap chole + post op ERCP

9. 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

10. 1 stage procedure (Lap cholecystectomy + IOC +/- LECBD)

11. 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

12. 1 stage procedure Methods for closure of choledochotomy T-T closure
Primary closure with stent
Primary closure without stent

13. 1 stage procedure Factors affecting the result of LECBD
Approach to LECBD (Trans-cystic vs choledochotomy)
Method for closure of choledochotomy
Morbidity
Bile leakage

14. 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

15. Evidence?

16. 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

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

18. 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

19. 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%)

20. 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

21. 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

22. Table 1
                                                                                                                                                                                                                          

23. 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)

24. 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)

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

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

27. 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 ( Vs minutes, p=0.52)
Shorter postoperative hospital stay (4 Vs 8 days, p<0.001)

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

29. UCH experience for LECBD

30. UCH experience 2005-2006 Case number for LECBD Age Operation time25
Age
Mean 70.3 (47-87)
Operation time
Mean 212 mins ( )
Stone clearance rate
96% (1 case with residual CBD stones)

31. 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

32. 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%

33. UCH experience
Follow-up period
5-20 months

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

35. 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

36. End