Background
Between 10% to 18% of people undergoing cholecystectomy for gallstones have common bile duct stones. Treatment of the bile duct stones can be conducted as open cholecystectomy plus open common bile duct exploration or laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC + LCBDE) versus pre- or post-cholecystectomy endoscopic retrograde cholangiopancreatography (ERCP) in two stages, usually combined with either sphincterotomy (commonest) or sphincteroplasty (papillary dilatation) for common bile duct clearance. The benefits and harms of the different approaches are not known.

Objectives
We aimed to systematically review the benefits and harms of different approaches to the management of common bile duct stones.

Search methods
We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7 of 12, 2013) in The Cochrane Library, MEDLINE (1946 to August 2013), EMBASE (1974 to August 2013), and Science Citation Index Expanded (1900 to August 2013).

Selection criteria
We included all randomised clinical trials which compared the results from open surgery versus endoscopic clearance and laparoscopic surgery versus endoscopic clearance for common bile duct stones.

Data collection and analysis
Two review authors independently identified the trials for inclusion and independently extracted data. We calculated the odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI) using both fixed-effect and random-effects models meta-analyses, performed with Review Manager 5.

Main results
Sixteen randomised clinical trials with a total of 1758 randomised participants fulfilled the inclusion criteria of this review. Eight trials with 737 participants compared open surgical clearance with ERCP; five trials with 621 participants compared laparoscopic clearance with pre-operative ERCP; and two trials with 166 participants compared laparoscopic clearance with postoperative ERCP. One trial with 234 participants compared LCBDE with intra-operative ERCP. There were no trials of open or LCBDE versus ERCP in people without an intact gallbladder. All trials had a high risk of bias.

There was no significant difference in the mortality between open surgery versus ERCP clearance (eight trials; 733 participants; 5/371 (1%) versus 10/358 (3%) OR 0.51;95% CI 0.18 to 1.44). Neither was there a significant difference in the morbidity between open surgery versus ERCP clearance (eight trials; 733 participants; 76/371 (20%) versus 67/358 (19%) OR 1.12; 95% CI 0.77 to 1.62). Participants in the open surgery group had significantly fewer retained stones compared with the ERCP group (seven trials; 609 participants; 20/313 (6%) versus 47/296 (16%) OR 0.36; 95% CI 0.21 to 0.62), P = 0.0002.

There was no significant difference in the mortality between LC + LCBDE versus pre-operative ERCP +LC (five trials; 580 participants; 2/285 (0.7%) versus 3/295 (1%) OR 0.72; 95% CI 0.12 to 4.33). Neither was there was a significant difference in the morbidity between the two groups (five trials; 580 participants; 44/285 (15%) versus 37/295 (13%) OR 1.28; 95% CI 0.80 to 2.05). There was no significant difference between the two groups in the number of participants with retained stones (five trials; 580 participants; 24/285 (8%) versus 31/295 (11%) OR 0.79; 95% CI 0.45 to 1.39).

There was only one trial assessing LC + LCBDE versus LC+intra-operative ERCP including 234 participants. There was no reported mortality in either of the groups. There was no significant difference in the morbidity, retained stones, procedure failure rates between the two intervention groups.

Two trials assessed LC + LCBDE versus LC+post-operative ERCP. There was no reported mortality in either of the groups. There was no significant difference in the morbidity between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 13/81 (16%) versus 12/85 (14%) OR 1.16; 95% CI 0.50 to 2.72). There was a significant difference in the retained stones between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 7/81 (9%) versus 21/85 (25%) OR 0.28; 95% CI 0.11 to 0.72; P = 0.008.

In total, seven trials including 746 participants compared single staged LC + LCBDE versus two-staged pre-operative ERCP + LC or LC + post-operative ERCP. There was no significant difference in the mortality between single and two-stage management (seven trials; 746 participants; 2/366 versus 3/380 OR 0.72; 95% CI 0.12 to 4.33). There was no a significant difference in the morbidity (seven trials; 746 participants; 57/366 (16%) versus 49/380 (13%) OR 1.25; 95% CI 0.83 to 1.89). There were significantly fewer retained stones in the single-stage group (31/366 participants; 8%) compared with the two-stage group (52/380 participants; 14%), but the difference was not statistically significantOR 0.59; 95% CI 0.37 to 0.94).

There was no significant difference in the conversion rates of LCBDE to open surgery when compared with pre-operative, intra-operative, and postoperative ERCP groups. Meta-analysis of the outcomes duration of hospital stay, quality of life, and cost of the procedures could not be performed due to lack of data.

Authors' conclusions
Open bile duct surgery seems superior to ERCP in achieving common bile duct stone clearance based on the evidence available from the early endoscopy era. There is no significant difference in the mortality and morbidity between laparoscopic bile duct clearance and the endoscopic options. There is no significant reduction in the number of retained stones and failure rates in the laparoscopy groups compared with the pre-operative and intra-operative ERCP groups. There is no significant difference in the mortality, morbidity, retained stones, and failure rates between the single-stage laparoscopic bile duct clearance and two-stage endoscopic management. More randomised clinical trials without risks of systematic and random errors are necessary to confirm these findings.

/pdf/surgical-versus-endoscopic-treatment-of-bile-duct-stones-52cgdfeoln.pdf

Surgical versus endoscopic treatment of bile duct stones

OBJECTIVE We conducted a retrospective 4-year study of patients undergoing laparoscopic cholecystectomy at a freestanding ambulatory surgery center. Data on rates of hospital admission, conversion to open surgery, bile duct injury, postoperative bile leakage, and incidence of choledocholithiasis were analyzed. The success rate for dynamic fluoroscopic intraoperative cholangiography was computed, and outpatient laparoscopic common bile duct exploration and anesthetic management were reviewed. METHODS Patient charts from the ambulatory surgery center, office, and hospital were reviewed over a 4-year period commencing in October 1999. All cases were performed by 1 of 3 surgeons who are experienced with outpatient laparoscopic cholecystectomy and practice routine dynamic fluoroscopic intraoperative cholangiography. RESULTS A total of 338 laparoscopic cholecystectomies were performed. Dynamic fluoroscopic intraoperative cholangiography was successfully performed in 89% (n = 302). No instances of bile duct injury or conversions to open surgery were reported. A 0.89% (n = 3) incidence of postoperative bile leak occurred. Six patients were admitted for inpatient care for a rate of 1.78%. Choledocholithiasis occurred in 2.0% and was managed successfully in the ambulatory setting. CONCLUSION Laparoscopic cholecystectomy can be adapted to the freestanding ambulatory surgery environment with very high standards of care and very low complication rates.

Laparoscopic cholecystectomy and management of biliary tract stones in a freestanding ambulatory surgery center.

Background
Increasingly, laparoscopic biliary surgeons are undertaking laparoscopic cholecystectomy and laparoscopic common bile duct exploration for patients with cholelithiasis and choledocholithiasis. In laparoscopic common bile duct exploration a flexible choledochoscope is ordinarily used, and with this instrument the surgeon usually fails to remove large impacted stones. In contrast with use of a rigid nephroscope it is possible to remove all common bile duct stones irrespective of size and degree of impaction. The present study evaluates the efficiency of rigid nephroscope for managing common bile duct stones laparoscopically.

Use of Rigid Nephroscope for Laparoscopic Common Bile Duct Exploration—A Single-Center Experience

Background:

Patients with cholelithiasis and choledocholithiasis are increasingly managed with laparoscopic bile duct exploration and cholecystectomy. Large impacted bile duct stones continue to defy laparoscopic extraction. This study explored the feasibility of laparoscopic bile duct clearance using a rigid nephroscope, which is suited to extracting large stones.



Method:

This prospective study recruited patients with large bile duct stones and a bile duct wider than 8 mm on ultrasonography. In addition to standard ports for laparoscopic cholecystectomy, a custom-made 9-mm port was introduced in the epigastrium for the rigid nephroscope, which was negotiated into the bile duct through a choledochotomy. Rigid graspers and lithotripters were introduced through the nephroscope to fragment and remove the calculi.



Results:

Between December 2005 and September 2008, 18 patients had nephroscope-guided bile duct exploration (mean(s.d.) age 49(13·9) years, bile duct diameter 11·3(2·3) mm). Three patients had solitary stones and 15 had multiple calculi. Most of the stones were removed with graspers, but the lithotripter was required in five patients. The mean(s.d.) hospital stay was 6(2·3) days. Two patients required postoperative endoscopic retrograde cholangiopancreaticography for residual stones.



Conclusion:

The rigid nephroscope was useful for laparoscopic bile duct exploration, particularly for large impacted stones. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Laparoscopic common bile duct exploration using a rigid nephroscope

Background
Given the limitations and risks associated with current treatments for common bile duct (CBD) stones, the authors placed a spontaneously removed endobiliary J stent in the distal CBD to decompress the biliary tract and performed a primary closure of the CBD after laparoscopic common bile duct exploration (LCBDE).

Spontaneously removed endobiliary J stent drainage after laparoscopic common bile duct exploration

Background: Laparoscopic common bile duct exploration (LCBDE) has proved to be a safe, cost-effective way to treat common bile duct (CBD) stones. Despite this, LCBDE has not gained widespread adoption by surgeons. The technique has proved difficult to master, and damage to the fragile choledochoscope by grasping forceps and passage through the port valves has been problematic. Cases involving large, impacted, or multiple stones have required conversion to open exploration of CBD. Methods: The Multichannel Instrument Guide (MIG) is introduced as a solution for these problems. The MIG is a J-shaped plastic extrusion with three lumens. It is flexible and can be straightened for insertion through a 10-mm port. The MIG facilitates insertion of a flexible 2.8- to 3.2-mm choledochoscope into the CBD. At the same time, additional tools such as balloon or irrigation catheters and lithotripters can be introduced into the CBD. These can be manipulated under video guidance via the choledochoscope. This procedural multitasking allows for a more efficient LCBDE. The authors describe their initial experience using the MIG for 23 patients. Results: Of the 23 patients who underwent LCBDE procedures, 20 had stones in the CBD. Multiple stones were present in 48% of the patients; impacted stones were present in 26% of the patients; and stones larger than 1 cm were present in 26% of the patients. A 95% stone clearance rate was achieved. Difficult cases with large, impacted or multiple stones were resolved using the MIG. Two choledochoscopes were damaged; one during surgery and one during cleaning and storage. Conclusions: The MIG has demonstrated significant advantages over previously described techniques. The device secures biliary tract access and allows procedural multitasking while protecting the delicate and expensive equipment. Subsequently, a simplified technique algorithm can be followed that may encourage more surgeons to adopt the routine performance of LCBDE.

A stone extraction facilitation device to achieve an improved technique for performing LCBDE

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A stone extraction facilitation device to achieve an improved technique for performing LCBDE