Laparoscopic management of common bile duct stones. A multi-institutional SAGES study. Society of American Gastrointestinal Endoscopic Surgeons.
Laparoscopic common bile duct exploration (CBDE) was the subject of a multi-institutional study on 226 patients from 19 major hospital centers. Female patients predominated (2.3:1); the average age was 54; 75% of cases were chronic, and the remainder were acute. Although 97% had preoperative ultrasonograms, only 12% showed a stone in the dilated common bile duct. The alkaline phosphatase was elevated in 41% and the serum bilirubin in 28% of cases. Preoperative endoscopic retrograde cholangiography with sphincterotomy (ERC-ES) was performed in 8.5%; there was a successful stone extraction in less than half the cases. Cholangiography was performed in 99.5%, and in 94% of those cases, stones were found. In 83% of cases, stones were removed through the transcystic approach, and in 17% removal was throughout the CBD. In the majority of cases, the choledochoscope and wire basket (34%), irrigation (33%), or a combination of both was employed. In the transcystic group, 5% were converted to open procedures due to technical difficulty, as contrasted with the trans-CBD route, where the conversion rate was 19%. There were two ductal injuries. Minor complications occurred in 5.7% within 24 h; there was one death (0.4%). Within 30 days, the morbidity rate was 7% and there were no deaths. Retained stones were discovered in 2.6% of cases. Laparoscopic CBDE is a feasible approach for CBD stones which permits a definitive procedure in one stage, without pre- or postoperative ES. It is a skill which should be mastered by the biliary surgeon. Further improvement in instrumentation and technique should make the laparoscopic approach not only comparable but preferable to the standard open choledocholithotomy.
Berci
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G
Department of Surgery, Cedars-Sinai Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048.
Morgenstern
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L
D002758:Cholangiography; D002760:Cholangiopancreatography, Endoscopic Retrograde; D017081:Cholecystectomy, Laparoscopic; D003135:Common Bile Duct / Q000601:surgery*; D005260:Female; D042882:Gallstones / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000601:surgery*; D006801:Humans; D015994:Incidence; D007430:Intraoperative Care; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology; D011446:Prospective Studies; D016717:Sphincterotomy, Endoscopic