A proposed difficulty grading system for laparoscopic bile duct exploration: benefits to clinical practice, training and research

Abstract

Background A gap remains between the mounting evidence for single session management of bile duct stones and the adoption of this approach. Laparoscopic bile duct exploration (LBDE) is limited by the scarcity of training opportunities and adequate equipment and by the perception that the technique requires a high skill-set. The aim of this study was to create a new classification of difficulty based on operative characteristics and to stratify postoperative outcomes of easy vs. difficult LBDE irrespective of the surgeon’s experience. Methods A cohort of 1335 LBDEs was classified according to the location, number and size of ductal stones, the retrieval technique, utilisation of choledochoscopy and specific biliary pathologies encountered. A combination of features indicated easy (Grades I and II A & B) or difficult (Grades III A and B, IV and V) transcystic or transcholedochal explorations. Results 78.3% of patients with acute cholecystitis or pancreatitis, 37% with jaundice and 46% with cholangitis had easy explorations. Difficult explorations were more likely to present as emergencies, with obstructive jaundice, previous sphincterotomy and dilated bile ducts on ultrasound scans. 77.7% of easy explorations were transcystic and 62.3% of difficult explorations transductal. Choledochoscopy was utilised in 23.4% of easy vs. 98% of difficult explorations. The use of biliary drains, open conversions, median operative time, biliary-related complications, hospital stay, readmissions, and retained stones increased with the difficulty grade. Grades I and II patients had 2 or more hospital episodes in 26.5% vs. 41.2% for grades III to V. There were 2 deaths in difficulty Grade V and one in Grade IIB. Conclusion Difficulty grading of LBDE is useful in predicting outcomes and facilitating comparison between studies. It ensures fair structuring and assessment of training and progress of the learning curve. LBDEs were easy in 72% with 77% completed transcystically. This may encourage more units to adopt this approach. Graphical abstract

Surgical strategies for challenging common bile duct stones in the endoscopic era: A comprehensive review of current evidence

“…Also, 17% of LCBDE cases were converted to open CBDE in patients who underwent previous biliary tract surgery, while intraoperative blood loss, hospital stay, and time to oral diet were significant better in LCBDE than in open CBDE[ 57 ]. The study on grading the difficulty of CBDE, Nassar et al [ 58 ] found that difficult cases often present emergently, with symptoms like obstructive jaundice and prior sphincterotomy. Easy cases typically undergo TC exploration, whereas difficult cases were more likely to undergo TD exploration.…”

“…Choledochoscopy was more commonly utilized in difficult cases. As difficulty increased, there was a rise in the use of biliary drains, open conversions, operative time, complications, hospital stay, readmissions, and retained stones[ 58 ].…”