300 Laparoscopic Bile Duct Explorations Results and Complications Ahmad Nassar Laparoscopic and Upper GI Service Monklands Hospital Lanarkshire, Scotland Lanarkshire, Scotland

Introduction EAES ductal stone study (December 1996) Multi-centre prospective randomized trial Single stage vs. 2 stage CBD clearance – Equal success rates – Shorter hospital stay for single stage – Cost benefits

Scottish Survey Questionnaire sent to Scottish surgeons Twice 5 years apart Response: –157 in 1998 (Group A) –77 in 2002 (Group B) Laparoscopic exploration was available to: –14.6% of surgeons Group A (by themselves) –33.8% of surgeons Group B (by themselves)

Scottish Survey Although more surgeons capable, less willing to do Laparoscopic exploration was considered the future by 26 surgeons in Group A, but only 18 surgeons in Group B LBDE Group A Group B Non- responder 36 (22.9%) 4 (5.2%) All-comers 2 (1.3%) 0 (0%) Often 3 (1.9%) 3 (3.9%) Occasional 18 (11.5%) 29 (37.6%) Never 98 (62.4%) 41 (53.2%)

Patients and Methods Prospective study over 13 years One stage management of all-comers including biliary emergencies Four trocar laparoscopic access Routine intraoperative cholangiogram Transcystic attempts at duct clearance initially Followed by dochotomy ± drainage

Patients and Methods 1680 biliary procedures on a referral firm All suspected ductal calculi and most other emergencies 300 bile duct explorations – Transcystic approach 169 patients – Dochotomy 131 patients Glucagon + flushing attempted Glucagon + flushing attempted Followed by trawling with Dormia Followed by trawling with Dormia Prior to choledochoscopic explorations Prior to choledochoscopic explorations

Results Lap. Explorations (300) Emergency admissions 201 (66%) Explorations in last 5 years 216 (72%) Bile duct stone suspicion 243 (81%) Mean age 59.1 years Whole series (1680) Emergency admissions for series 501 (29.8%) Preceding 8 years 84 (32.3%) Bile duct stone suspicion 490 (30%) Mean age 50.5 years

Results Intraoperative cholangiogram –ve in 252 patients out of 501 with suspicious CBD stones (50.3%) IOC positive in 92 patients with no CBD stone suspicion n=1170 (7.8%). Presentations Lap. Explorations (n= 300) Jaundice131 Cholangitis24 Pancreatitis21 U/S dilatation/stones 182 Deranged LFTs 111 CBD stone risk

Results – Biliary Drainage No Drain Cystic duct drain T-tube TCE CBDE * Converted 10 (3 bypass) -4

Conversions DateAgeSexTypeCauseProcedure Sept 92 42MTCE No instruments for cbde Open CBDE April 93 42FCBD Large impacted stones Open April 93 40FCBD Large impacted stones Open Bypass Dec 94 74FCBD Stricture/ ? malignant Open Bypass May 95 39FCBD Impacted stones Open Bypass June 95 65FCBD Multiple 30+, 2 impacted Open CBDE June 97 78FCBDImpacted Open Bypass Sept 97 37FCBD 60 stones+ 2 impacted Open CBDE June 02 71FCBD DONE, SB adhesions at umbilicus, dense Release resection Feb 04 26MCBD DONE Mirizzi 2 needing Bypass

Results and Complications Mean difficulty Mean operating time Subhepatic drain Fever Wound infection Biliary leak TCE min 12875%353 CBDE min Converted % min 9111 TCE= transcystic exploration CBDE= common bile duct exploration Open= conversion to open

Morbidity Parameters Retained stones: % Postoperative ERCP ( all causes): 24 8% Recurrent Stones: 5 1.6% Re-operation: 3 1% Mortality: 1 0.3% - SMA ischaemia/ infarction - SMA ischaemia/ infarction

Results - Means

Discussion Previous studies have proved cost- effectiveness and decreased hospital stay for laparoscopic biliary exploration Surgeons who overcome learning curve are still reluctant to adopt technique 51.3% of patients who have clinical, ultrasound or biochemical suspicion of duct stones would have unnecessary preoperative investigations

Discussion Eight percent silent stones were picked up by routine intraoperative cholangiogram Transcystic ductal exploration: – Clearance achieved with glucagon, flushing and Dormia trawling in 32.2% of patients – Less morbidity – Decreased operative time, shorter hospital stay and shorter presentation-resolution than choledochotomy – Also facilitates simple postoperative biliary drainage

Conclusion Laparoscopic single session management of ductal stones is cost-effective with shorter hospital stay than multiple stage management Laparoscopic single session management of ductal stones is cost-effective with shorter hospital stay than multiple stage management Simple transcystic manoeuvres may clear the ducts without formal exploration Simple transcystic manoeuvres may clear the ducts without formal exploration This technique is advocated in preference to endoscopic clearance for surgeons beyond the learning curve This technique is advocated in preference to endoscopic clearance for surgeons beyond the learning curve