Introduction

The incidence of common bile duct stones associated with cholelithiasis increases with age and is about 15-20% in the 8th decade of life, but its management is still controversial¹. There are usually two different treatment options: preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (two-stage procedure), or single-stage treatment with intraoperative resection of common bile duct stones during laparoscopic cholecystectomy. The main differences between the two treatments include length of hospital stay, costs and training in laparoscopic surgery^1,2.

The primary outcome of the present study was to evaluate the efficacy and safety of single-stage laparoscopic surgery in a consecutive series of patients with cholelithiasis and choledocholithiasis over a period of 10 years. The secondary outcome was to analyze the variables than can modify the efficacy and safety of this approach.

Material and methods

We conducted a retrospective study at the department of General Surgery, Hospital Cosme Argerich, of prospectively collected data retrieved from an ad hoc database of patients with choledocholithiasis diagnosed by routine intraoperative cholangiography (IOC) over a 10-year period (from July 2008 and July 2018). Patients with previous cholecystectomy (residual stones), severe acute cholangitis, high perioperative risk and severe acute pancreatitis were excluded.

Preoperative variables

▪▪Age

▪▪Sex

▪▪Diagnosis on admission: symptomatic cholelithiasis, acute cholecystitis, acute biliary pancreatitis and choledocholithiasis.

Intraoperative variables

▪▪Operative time

▪▪Rate of successful transcystic exploration and successful choledochotomy

▪▪Conversion rate

▪▪Rate of favorable versus unfavorable cystic duct anatomy

▪▪Relation between cystic duct diameter and gallstone size

▪▪Prevalence of common bile duct stones

▪▪Number, size, and site of gallstones

Postoperative variables

▪▪Complications according to the Clavien-Dindo classification³

▪▪Length of hospital stay

▪▪Residual stones

▪▪Biliary fistulas

▪▪Reoperations

Definitions

▪▪Choledocholithiasis: common bile duct diameter > 8 mm or visualization of the gallstone by ultrasound, total bilirubin values > 2 mg/dL or alkaline phosphatase (ALP) > 200 IU/L.

▪▪Favorable cystic duct anatomy: when the cystic duct enters the extrahepatic bile duct from the right lateral aspect and the course is not tortuous. In the absence of this condition, cystic duct anatomy is unfavorable. The cystic duct anatomy may become favorable after further dissection (Fig. 1).

▪▪The relation between cystic duct diameter and gallstone size was defined as > or < 1 using the size of the clamp to estimate the diameter (Fig. 2A).

▪▪Proximal gallstones: presence gallstones proximal to the cystic duct- main bile duct junction (Fig. 2B).

▪▪Unsuspected choledocholithiasis: when gallstones in the common bile duct are identified during IOC in patients with a preoperative diagnosis other than choledocholithiasis.

▪▪Failed transcystic approach: failure to clear gallstones through transcystic exploration, after completing all the available maneuvers to improve efficiency (further dissection, balloon dilation, etc.).

▪▪Total acute main bile duct obstruction syndrome was defined as progressive increase in bilirubin and ALP levels.

▪▪Bile leak: leakage of bile from the abdominal drain placed in the Morrison’s space or need for percutaneous placement of an abdominal drain.

Results

During the period analyzed, 2447 laparoscopic cholecystectomies were performed, and IOC were carried out in 99.7% of the cases; 416 (17%) presented common bile duct stones.

Preoperative variables

▪▪Most patients were women (275 vs.141) and mean age was 33 years (range 18-88).

▪▪The ASA risk was grade 1 in 158 (38%) patients, grade 2 in 221 (53%) and grade 3 in 37 (9%).

▪▪The diagnoses suspected in 227 (54.5%) patients were jaundice, acute cholangitis, and acute biliary pancrea titis with bile duct dilation.

▪▪In 189 (45.5%) patients the diagnoses were not sus pected and included 72 acute cholecystitis, 70 sympto matic cholelithiasis, 47 acute biliary pancreatitis.

Intraoperative variables

The efficacy of the laparoscopic approach was 99%. Mean operative time was 81 minutes (range 30- 250).

▪▪The global efficacy of the transcystic exploration was 81.2%, with an operative time of 55 minutes and mean length of hospital stay of 24 hours, without complications. The efficacy varied according to the different variables analyzed (Tables 1 and 2, Figures 4 and 5).

▪▪Choledochotomy was necessary in 78 cases (18.75%) with mean operative time of 94 minutes and mean hospital length of stay of 72 hours; 14 patients presented developed (17.9%). Table 3 shows the indication of choledochotomy according to the preoperative diagnosis. After choledochotomy, 34 bile duct repair procedures over a Kehr’s T tube were performed, followed by 24 primary closures of the common bile duct and 20 bilio-digestive bypass procedures (14 choledochoduodenostomies and 6 Roux-en-Y hepaticojejunostomies).

▪▪Conversion to open surgery was necessary in 4 patients (1.7%), all of them with preoperative diagnosis of choledocholithiasis. The reasons for conversion were multiple adhesions in 2 cases, management of hemostasis and removal of an impacted gallstone in 1 patient with total acute main bile duct obstruction syndrome and need for hepaticojejunostomy in another patient with total acute main bile duct obstruction syndrome.

Postoperative variables

Mean length of hospital stay was 30 hours (range 24-240 hours). There were no deaths or bile duct injuries. Seventeen patients (4%) with preoperative diagnosis of choledocholithiasis developed postoperative complications (Table 4).

▪▪Two patients (0.48%) required reoperation due to bleeding with hemodynamic impairment. Another 4 patients presented bleeding without hemodynamic impairment and were managed with a conservative approach.

▪▪Bile leaks occurred in 8 cases (1.9%); 5 were biliary leaks with favorable outcome with conservative treatment (based on the assessment of drain output) and 3 presented as biloma that required percutaneous treatment. The 8 cases developed after choledocotomies: 5 after bilio-digestive bypass procedures and 3 after primary closure of the common bile duct (without papillary dilation).

▪▪Two patients presented surgical site infection in the umbilicus that was successfully treated with antibiotics.

▪▪Other complications included placement of a nasogastric tube due to vomiting in two patients, and one patient with high preoperative risk and prolonged hospital stay developed pneumonia and required antibiotics.

▪▪Five patients (1.2%) presented residual stones. The diagnosis was made by magnetic resonance cholangiopancreatography and the patients were successfully treated with ERCP.

Discussion

Over the past decades, several prospective randomized trials and meta-analyses have demonstrated the benefits of the one-stage approach for the management of cholelithiasis and choledocholithiasis². Shorter length of hospital stay, lower incidence of complications are lower costs are some advantages observed. Nevertheless, the operative time is longer with the one-stage approach; the procedure requires more sophisticated equipment and trained staff and is not usually paid accordingly. For these reasons, the two-stage approach is most commonly used in daily practice^7,8. In our experience, and considering the aforementioned facts, the efficacy of laparoscopy for the treatment of common bile duct stones in a one-stage strategy had an efficacy of 99%. Most cases were successfully treated by transcystic exploration. In line with other reports, the incidence of complications, costs and length of hospital stay were lower when the common bile duct stones were cleared by transcystic exploration than by choledocotomy⁹.

In our series, the success rate with the trancystic exploration was high (81%) but other studies have shown figures of about 95%^2,9,10. This difference could be explained by the exclusion of cases with preoperative diagnosis of choledocholithiasis. The comparison with our previous experience is favorable: the effectiveness of the transcystic exploration improved from 75 to 81%¹¹. This could be due to greater use of maneuvers in case of unfavorable cystic duct anatomy such as further dissection, new cysticotomy, cystic duct lithotomy, cysticotomy over the common bile duct stone, transcystic antegrade papillary dilation and, less frequently, the use of blunting instruments to bring down intrahepatic stones.

The major limitations of the transcystic approach were a relation between the cystic duct diameter and gallstone size < 1, gallstone size > 10 mm and preoperative diagnosis of choledocholithiasis.

Half of the conversions to open surgery in this series were due to an unusual presentation of choledocholithiasis. These patients presented total acute main bile duct obstruction syndrome characterized by jaundice with progressive increase in total bilirubin and alkaline phosphatase levels. The IOC showed a stone usually lodged in the mid or distal common bile duct that completely blocked the passage of dye and of the basket through the trancystic approach or choledocotomy. In many cases, the common bile duct presents a stricture distal to the stone, a situation hardly favorable to solve endoscopically^12,13. We believe that these patients may benefit from preoperative ERCP with stent placement, pushing the stone into the dilated area of the bile duct to prevent further impaction, followed by stone clearance through the transcystic approach or choledochotomy. Some authors state that placement of an endoprosthesis may reduce stone size, allowing later clearance of unextractable stones by open surgery or endoscopy^14,15. This hypothesis is being evaluated in a prospective randomized trial. Laparoscopic common bile duct exploration and holmium laser lithotripsy could be another option for these cases^16,17.

Conclusions

In non-selected patients with cholelithiasis and common bile duct stones, laparoscopic exploration has an efficacy > 99% when performed by trained operators with adequate instruments.

The efficacy of transcystic exploration in patients without choledocholithiasis is 93% but is significantly reduced in those with choledocholithiasis (70%). The incidence of complications is 0% in those without choledocholithiasis and 7.4% in patients with choledocholithiasis.

We suggest the transcystic approach as the first option to treat common bile duct stones due to the high efficacy of the method and the low rate of complications.

The relation between cystic duct diameter and stone size is the most important predictor of success.

We emphasize the need for training and recommend routine IOC with the primary aim of reducing major bile duct injuries and the secondary aim of solving choledocholithiasis in a single-stage procedure.