Introduction

Choledocholithiasis may have special presentations which make endoscopic and surgical treatments difficult with complications or may require several procedures to be solved, thus increasing morbidity.

Transcystic instrumentation (TCI)¹ is the first therapeutic option for choledocholithiasis associated with cholelithiasis. Choledochotomy is performed if this option fails, followed by primary closure of the common bile duct (CBD), placement of a T-tube or bilio-digestive bypass. Nowadays, primary closure of the CBD is the most accepted option² but is not free of complications, and bile leak is the most common one. In cases of moderate or severe cholangitis, transgastric endoscopic biliary drainage using plastic stents is indicated³. After sepsis has been controlled, the definitive treatment of cholelithiasis and choledocholithiasis is carried out. Treatment of these cases involves two procedures: an additional endoscopy to remove the stent and stones, followed by cholecystectomy (Table 1).

Table 1 Comparison of the techniques used to reduce biliary leak after primary closure of the common bile duct 

The aim of this paper is to describe two surgical techniques: one to potentially decrease biliary leaks in primary closure of the CBD and the other to manage choledocholithiasis associated with plastic stents in a single procedure.

Surgical technique

Reduction of biliary leaks in primary closure of the CBD

When TCI fails, we choose laparoscopic choledochotomy and we remove the stones using baskets. We check that the stones have been extracted with a new intraoperative cholangiography (IOC). We then introduce a hydrophilic guidewire (Roadrunner- Cook Medical) through the choledochotomy under fluoroscopic guidance via the 5-mm port placed in the right lumbar region. When the guidewire reaches the duodenum, we slide the balloon dilator (Quantum TTC - Cook Medical), positioning it in the papilla and insufflating it at a pressure of 20 atm. Dilation is conducted progressively using balloons (Quantum TTCCook Medical) of 8 and 12 French in diameter for 10-15 seconds. When the balloon is properly positioned, an hourglass pattern appears due to the notch it produces in the papilla, which disappears with dilatation (Figure 1). After progressive dilatation (8 and 12 mm), we perform bile duct repair using separate stitches with absorbable material (PDS 4-0). We then repeat IOC though the cystic duct to check the absence of leakage and evaluate papillary evacuation; then, a drain is placed.

Figure 1 Inflated balloon showing the notch produced in the papilla. Hourglass image (black arrow) 

We used this technique in 10 patients; 9 presented favorable outcome and were discharged after 48 hours. One patient presented moderate epigastric pain 24 hours after surgery in the absence of biliary leak, with hyperamylasemia, but without abnormal images on the abdominal computed tomography scan. Medical treatment was indicated with favorable response and the patient was discharged 72 hours later.

Extraction of plastic stent by TCI

After the acute cholangitis has been managed, surgery is scheduled. The procedure is performed during laparoscopic cholecystectomy. The stones and the stent are removed with the basket by TCI; the stent is grasped by its flaps and folds into a V-shape upon extraction. If the previous maneuver fails, we perform a new dissection and a cystotomy closer to the junction between the cystic duct and the CBD and we introduce a Maryland forceps through the cystic duct to remove the stent (Figure 2). Then, we remove the common bile duct stones with the same basket or advance it into the duodenum after progressive papillary balloon dilation when the cystic duct to stone diameter ratio is < 1 (the size of the cystic duct is smaller than the size of the stone)⁴. We used preformed polypropylene knots to close the cystic duct. The final step is cholecystectomy with placement of a drain in the Morrison’s pouch.

Figure 2 Stent removal via transcystic approach with a Maryland forceps. 

Twelve patients were treated with this technique (Table 2).

Table 2 Characteristics of patients with transcystic removal of the plastic stent 

The choledocholithiasis was managed with a Dormia basket in all the cases, except in one patient who had a cystic duct to stone diameter ratio < 1 and required papillary balloon dilation to advance the stone into the duodenum; the stent could be extracted using a Dormia basket. Characteristics of patients with transcystic removal of the plastic stent: all the patients evolved with favorable outcome and were discharged after 24 hours. There were no complications after 3-month follow-up.

Discussion

There are no publications in PubMed on the use of antegrade papillary dilation to prevent the development of biliary fistulas in primary closure of the CBD or on the use of TCI to remove stents and common bile duct stones as the first option for the treatment of cholangitis after endoscopic retrograde cholangiopancreatography (ERCP).

There are currently three methods to close the choledochotomy: placement of a T-tube, primary closure of the CBD and bilio-digestive bypass. T-tubes are almost no longer used due to possible biliary leaks during tube extraction, water and electrolyte imbalances, postoperative discomfort and longer length of hospital stay^2,3.

Bilio-digestive bypass procedures are reserved for selected cases (primary common bile duct stones or large common bile duct stones) because they are considered more complex interventions, with high rates of complications and conversion. Primary closure of the CBD is the ideal option; but is not free of complications and bile leak is the most common one⁵. Three techniques are mentioned in the bibliography to decrease the rate of this complication: antegrade stenting, use of fibrin-collagen sealants covering the choledochorraphy, and a hybrid treatment combining primary closure of the CBD with insertion of nasobiliary catheter. The use of fibrin-collagen sealants has reduced the incidence of biliary leaks according to the authors, but few cases have been reported. This technique is only intended to seal a suture defect and does not act on intraluminal pressure⁶.

Primary closure of the CBD with antegrade stenting enables papillary flow during the postoperative period without increasing intraluminal pressure, an ideal situation for healing. Although the results are satisfactory in the different publications, this option requires a subsequent endoscopy for stent extraction, resulting in a two-stage procedure. It is also associated with complications due to stent migration and postoperative pancreatitis¹².

Hybrid treatment, which combines primary closure of the CBD and endoscopic insertion of a nasobiliary catheter, decreased the percentage of fistulas, but the number of cases is low and has a high incidence of postoperative pancreatitis. Our objection to this technique is that, once endoscopy has been performed, endoscopic stone clearance would be preferable, thus avoiding primary closure of the CBD. Other authors compare the use of a T-tube versus primary closure of the CBD with transpapillary insertion of a Nelaton tube by open surgery⁸. There were no biliary leaks in the 25 cases evaluated, but endoscopy was required to remove the tube in two cases; in the remaining cases, the tube was spontaneously expelled with bowel movements. Papillary dilation has been described for the percutaneous treatment of choledocholithiasis before cholecystectomy⁷, for residual choledocholithiasis and as a complement to TCI to enable the passage of stones into the duodenum in a single-step treatment, thus avoiding choledochotomy⁹. In all these cases the rate of complications is low.

Papillary dilation preserves the anatomy and functional integrity of the sphincter of Oddi preventing duodenal-biliary reflux with a low rate of complications and ensures achievement of two requirements described by Mirizzi (patency of the papilla and complete stone clearance). The effect of papillary dilation is temporary⁶ (approximately 7 days), resulting in tension-free healing and evacuation of probable residual debris (clots, stone debris). There are case reports of surgical removal of the stent after failed endoscopic attempts, but they required management with choledochotomy and T-tube insertion¹⁰.

The usual treatment of cholangitis requires at least two ERCPs and is associated with higher rate of complications (pancreatitis, perforation, bleeding, length of hospital stay and treatment costs)¹. Laparoscopic cholecystectomy in patients with in situ stent is usually more difficult due to fibrosis and inflammation. The study by Nair et al. compared three groups of patients: with previous ERCP, ERCP and stents and without ERCP. The authors did not systematically perform IOC and did not remove the stent during surgery; however, they reported a very high incidence of biliary leaks and conversion to open surgery in those with in situ stent, especially when stents were left in situ for long periods⁵. The bias of our study is that appointments for endoscopy are not readily available because patients with malignant obstructions are prioritized.

Conclusion

These techniques may be useful, as they mitigate the morbidity of these specific biliary procedures, decrease biliary leaks in primary closure of the CBD, and simultaneous surgical removal of stents and CBD stones avoid new endoscopies.

Therefore, we believe these options are valid; however, we should wait for prospective and randomized studies to demonstrate evidence of their benefits.