Transcystic Common Bile Duct Exploration (TCBDE) in the Management of Patients with Choledocholithiasis.
Abstracts
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Common bile duct stones discovered in the preop are managed with sphincterotomy during the endoscopic retrograde cholangiography (S-ERC).However in the era of laparoscopic cholecystectomy,choledocholithiasis can be found in 5-8% of patients during transoperative cholangiography.We report our results with the transcystic common bile duct exploration (TCBDE) in terms of succes of extraction of the common bile duct stones, morbidity, operative time, hospital stay and mortality.METHODS: From 1992 to 2001 we performed 300 laparoscopic cholecystectomies for symptomatic gallstone disease.We performed selective cholangiography (SC) in 75 patients (25%) according to elevated bilirrubin, AST,alkaline phosphatase,dilated common bile duct, remote jaundice or pancreatitis. If the SC resulted positive we performed dilatation of the cystic duct with a ballon catheter, then flexible choledochoscopy, and if we confirmed common bile duct stones proceeded to the extraction using 4 Fr wire baskets. RESULTS:SC was positive for in 27 cases (36%), with an incidence of common bile duct stones of 9% from the total group (27/300). Two patients were converted to open bile duct exploration, and four refered to postoperative S-ERC with complete succes. In the remaining 21 patients we performed the TCBDE and confirmed common bile duct stones in all of them for a 100% sensibility of the SC. We proceed to the extraction of the stones (num:1-8). We could extract the stones in 19 patients for a succes rate of 90.4%.We failed in 2 patients, one with multiple lithasis (8), and one with an impacted stone at the ampulla that were converted to open surgery. The mean operative time was 120+/-40 min.Postoperative complications were pulmonary atelectasis in one patient and urosepsis in another for a 9.5% morbidity rate.Hospital stay was 24-48hrs, and there was no operative mortality.CONCLUSIONS:Common bile duct stones can be diagnosed transoperative in 9% of the patients. Must of them can be treated with succes (90.4%)using the TSCBD and their complications, hospital stay, and recovery time is very similar to patients in whom only the laparoscopic cholecystectomy is performed.We found that multiple or impacted distal stones are risk factors for conversion.The benefits obtained by the minimal access surgery encourage that the TSCBD should become the primary strategy in the great majority of patients with common bile duct stones found during the SC. |
