1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. Current Evidence

12. 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): (US)

13. 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: (India)

14. 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: (Italy)

15. 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: (Spain)

16. 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: (UK)

17. 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: (Australia)

18. 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