Reclaiming the management of common duct stones in acute care surgery

Abstract

BACKGROUND Acute care surgery (ACS) is well positioned to manage choledocholithiasis at the time of laparoscopic cholecystectomy, but barriers to laparoscopic common bile duct exploration (LCBDE) include experience and the perceived need for specialized equipment. The technical complexity of this pathway is generally seen as challenging. As such, LCBDE is historically relegated to the “enthusiast.” However, a simplified, effective LCBDE technique as part of a “surgery first” strategy could drive wider adoption in the specialty most often managing these patients. To determine efficacy and safety, we sought to compare our initial ACS-driven experience with a simple, fluoroscopy-guided, catheter-based LCBDE approach during laparoscopic cholecystectomy (LC) to LC with endoscopic retrograde cholangiopancreatography (ERCP). METHODS We reviewed ACS patients who underwent LCBDE or LC + ERCP (pre−/postoperative) at a tertiary care center in the 4 years since starting this surgery first approach. Demographics, outcomes, and length of stay (LOS) were compared on an intention to treat basis. Laparoscopic common bile duct exploration was performed via using wire/catheter Seldinger techniques under fluoroscopic guidance with flushing or balloon dilation of the sphincter as needed. Our primary outcomes were LOS and successful duct clearance. RESULTS One hundred eighty patients were treated for choledocholithiasis with 71 undergoing LCBDE. The success rate of catheter-based LCBDE was 70.4%. Length of stay was significantly reduced for the LCBDE group compared with the LC + ERCP group (48.8 vs. 84.3 hours, p < 0.01). Of note, there were no intraoperative or postoperative complications in the LCBDE group. CONCLUSION A simplified catheter-based approach to LCBDE is safe and associated with decreased LOS when compared with LC + ERCP. This simplified step-up approach may help facilitate wider LCBDE utilization by ACS providers who are well positioned for a timely surgery first approach in the management of uncomplicated choledocholithiasis. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.

Contemporary management of common bile duct stone: What you need to know

“…26 This stepwise, catheter-based laparoscopic transcystic CBD exploration approach has been associated with a high success rate of biliary clearance and shorter length of stay compared with cholecystectomy with postoperative ERCP with minimal risk of perioperative complications. 27 Using a choledochoscope allows direct visualization of the stones as well as basket retrieval under direct vision. This requires additional placement of another 5 mm trocar in the right upper quadrant.…”

“…A cholangiogram is shot with the CBD sealed to flush the debris into the duodenum and to prevent flushing the debris into the hepatic ducts 26 . This stepwise, catheter-based laparoscopic transcystic CBD exploration approach has been associated with a high success rate of biliary clearance and shorter length of stay compared with cholecystectomy with postoperative ERCP with minimal risk of perioperative complications 27 …”

Clinical efficacy of laparoscopic cholecystectomy plus cholangioscopy for the treatment of cholecystolithiasis combined with choledocholithiasis

“…The combination of LC and laparoscopic common bile duct exploration (LCBDE) as a minimally invasive surgery like ERCP + LC, and this treatment can effectively treat both cholecystolithiasis and choledocholithiasis in one operation[ 9 ]. In the meta-analysis of Pan et al [ 10 ], LC + LCBDE ERCP + LC exhibited superior clinical efficacy and perioperative safety in patients with cholecystolithiasis combined with choledocholithiasis compared with ERCP + LC.…”