Single-step treatment of gall bladder and bile duct stones: a combined endoscopic-laparoscopic technique

The advent of endoscopic techniques changed surgery in many regards. In the management of cholelithiasis; laparoscopic cholecystectomy (LC) is today the treatment of choice. This has created a dilemma in the management of choledocholithiasis. Today a number of options exist, including endoscopic sphincterotomy (ES) before LC in patients with suspected common bile duct (CBD) stones, laparoscopic common bile duct exploration (LCBDE) by the transcystic approach or laparoscopic choledocotomy, open CBD exploration and postoperative ERCP. A major concern regarding both pre- and postoperative extraction of CBD stones (CBDS) by the ERCP is the risk of development of pancreatitis, also more than 10% of the preoperative ERCP is normal. More recently the alternative technique of combined LC with intraoperative ERCP and ES is emerging in an attempt to manage cholecysto-choledocholithiasis in a single-step procedure.

The aim of this work was to assess the treatment of common bile duct stones (CBDS) in a one-stage operation by laparoscopic cholecystectomy (LC) and intraoperative endoscopic retrograde cholangiopancreatography (LC+IO-ERCP) and endoscopic sphincterotomy (ES).

This study was carried out on 45 patients with gall bladder stones and with suspected or confirmed CBDS at the Gastrointestinal Surgery Unit in the Main Alexandria University Hospital. They were treated by a single-step procedure combining LC and IO-ERCP. Laparoscopic intraoperative cholangiography (IOC) was carried out to confirm the presence of CBDS. A soft-tipped guide-wire was passed through the cystic duct and papilla into the duodenum. A papillotome was inserted endoscopically over the guide-wire. Endoscopic sphincterotomy was performed and the stones were extracted with a retrieval balloon or with a Dormia basket. The surgical operating time, surgical success rate, postoperative complications, retained CBDS, and postoperative length of hospital stay were assessed.

There were 30 females and 15 males. Their mean age was 45.07+11.3 years (ranging from 27 to 65 years). Twenty-seven patients had confirmed CBDS by preoperative ultrasound (US) and/or MRCP. Eighteen patients were suspected for CBDS on clinical, laboratory and/or US basis. Conversion to open cholecystectomy occurred in one case due to severe adhesions at the Calot's triangle. IOC revealed the presence of CBDS in 36 patients. IO-ERCP with ES was performed successfully in 33 patients and stones were extracted endoscopically. Passage of the guide-wire through the papilla failed in three patients. Cholecystectomy was completed laparoscopically in 44 patients. The mean operative time was 119+14.4 min (ranging from 100 to 150 min). Minor postoperative complications occurred in 15 patients. No postoperative complications related to the procedure, i.e., pancreatitis, bleeding, perforation, were encountered. Patients regained their bowel motion on the next day and were discharged after a mean hospital stay of 2.55+0.89 days. None of the patients presented on the postoperative follow-up with symptoms, signs, laboratory or radiological evidence of retained CBDS. The mean duration of the postoperative follow-up was 9+4.07 months (ranging from 3 to 14 months).

The current study suggests that LC+IO-ERCP for the management of cholecysto-choledocholithiasis is a safe and aneffective technique with a low rate of post-ERCP pancreatitis. It offers another alternative for surgeons especially those who do not practice LCBDE to treat patients in a single setting. However, additional studies with larger patient populations are needed keeping in mind that the limiting characteristic is the proximity and availability of the endoscopic settings.