Role of operative flexible choledochoscopy in calculous biliary tract disease

In India, no study is available regarding the use of operative choledochoscopy in the management of choledocholithiasis. ERCP facilities are not always available at many centres and usually require the expertise of a medical gastroenterologist. In contrast, operative choledochoscopy is a simpler procedure that can easily be learned and practised by many surgeons at the time of CBD exploration.

To study the role of the flexible choledochoscopy in the diagnosis and management of calculous biliary tract disorders.

Twenty four patients with choledocholithiasis underwent flexible choledochoscopy. Stones were removed either with Desjardin's forceps or by choledochoscopic instrumentation. Postoperative T-tube cholangiography was done to detect any retained stones.

Flexible choledochoscopy was performed in a total of 24 patients. Choledochoscopy was done through a choledochotomy in 23 and through the cystic duct in one patient. The choledochoscope was used following conventional CBD exploration in 18 of the 23 patients. Complete clearance of stones was confirmed by choledochoscopy in 12 of the 18 patients and additional stones were seen in the remaining 6 patients. Fogarty balloon catheter and Dormia forceps were used to extract these stones. A CBD stricture was seen in 4 of these 18 patients and choledochoscopic biopsy was done in one of them. In 5 of the 23 patients, the choedochoscope was used as the initial exploring instrument. Impacted CBD stones were detected in 3 of the 5 patients, external compression of the CBD due to periampullary carcinoma in one and stones in both the ampulla and common hepatic duct in the last patient. Postoperative T-tube cholangiography was done in 10 patients and did not reveal any retained stones. Drainage procedures were carried out in 13 patients: 11 had choledochoduodenostomy and 2 had transduodenal sphincteroplasty. Choledochoscopy was a direct aid in choosing the operative procedure in 21 patients.

Flexible choledochoscopy is the most effective method of CBD exploration and is essential in all patients with choledocholithiasis. No additional morbidity or mortality is caused by this procedure.