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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 6  |  Issue : 2  |  Page : 90-95

Laparoscopic management of common bile duct stones: Stent Vs T-tube drainage


Department of Surgery, Government Medical College, Srinagar, Jammu and Kashmir, India

Date of Web Publication30-Nov-2016

Correspondence Address:
Mudasir F Hajini
Hajini Manzil, Noor Bagh Sopore, Baramulla, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.194987

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  Abstract 

Background: The management of concomitant gallbladder and common bile duct (CBD) stones is controversial. We study the outcomes of laparoscopic management of common bile duct (CBD) stones with stent placement and primary closure against T-tube drainage.
Patients and Methods: A series of 31 patients (17 females and 14 males) aged between 30 and 55 years, who underwent biliary decompression after laparoscopic CBD exploration to treat choledocholithiasis, was studied retrospectively from May 2009 to December 2015. The results in patients with stent (11) were compared with those who had T-tube drainage (20).
Results: Stent placement and T-tube drainage was achieved in all cases by choledochotomy after adequate clearance of CBD. No mortality was reported in our series. Patients with T-tube drainage had more morbidity and complications compared to stented patients. Stents were successfully removed in all cases in the postoperative follow up by endoscopy.
Conclusions: Laparoscopic CBD stenting is a safe method in the treatment of selected patients of CBD stones who need biliary decompression. Because of lower morbidity and shorter hospital stay compared with T-tube drainage, it should be considered as the first approach whenever biliary decompression is needed after LCBDE.

Keywords: Biliary stent, choledocholithiasis, choledochotomy, common bile duct, endoscopic retrograde cholangiopancreatography, nephroscope, T-Tube


How to cite this article:
Mir IS, Hajini MF, Rashid T, Sheikh VM, Bhat SN. Laparoscopic management of common bile duct stones: Stent Vs T-tube drainage. Arch Int Surg 2016;6:90-5

How to cite this URL:
Mir IS, Hajini MF, Rashid T, Sheikh VM, Bhat SN. Laparoscopic management of common bile duct stones: Stent Vs T-tube drainage. Arch Int Surg [serial online] 2016 [cited 2021 Jan 25];6:90-5. Available from: https://www.archintsurg.org/text.asp?2016/6/2/90/194987


  Introduction Top


Surgical techniques have advanced tremendously in the past decade, however, the management of concomitant gallbladder and common bile duct (CBD) stones still remains controversial and a matter of debate. Incidence of gallstones varies in the range of 6–10% in adult population.[1] Prior to the introduction of laparoscopic cholecystectomy as a standard care for gallstone disease, the incidence of choledocholithiasis was approximately 9–16% in patients who were taken up for open cholecystectomy.[2],[3] Approximately 7% of gallstone patients have concurrent CBD stones.[3] The incidence increases with age to over 80% in those who are over 90 years of age.[4]

Precisely, the management of CBD stones requires two separate teams: The gastroenterologist and the surgical team. In general, treatment of such patients includes cholecystectomy and clearance of CBD stones. There are several approaches to the treatment of CBD stones, including laparoscopic CBD exploration (LCBDE) and preoperative, intraoperative, and postoperative endoscopic retrograde cholangiopancreatography (ERCP). Despite all these options and improvement in minimally invasive techniques, many surgeons across the globe still perform open CBD exploration with or without external biliary drainage.

The concomitant laparoscopic CBD exploration with clearance of CBD stones during cholecystectomy has demonstrated many advantages when compared with other surgical techniques.[5] Laparoscopic CBD exploration has been found to be successful in 70% to greater than 90% of patients having CBD stones.[6] Laparoscopic CBD exploration, however, requires fine laparoscopic surgical skills with the availability of proper equipment facilities. The laparoscopic clearance of CBD stones can be achieved via two approaches, i.e., transcystic and choledochotomy. Both of these methods are useful and have precise indications. Further, in cases where patients need biliary decompression after stone clearance, a T-tube or a stent can be placed. It should be noted that a T-tube placed via a properly made choledochotomy has been associated with higher morbidity rates.[7] In this regard, placement of a stent via cystic duct (transcystic) or choledochotomy has been found to be a safe and valuable alternative to avoid T-tube related complications.[8]


  Patients and Methods Top


We present our experience of a retrospective case series conducted in our institution comparing the outcomes of T-tube and stent for biliary drainage in patients who underwent laparoscopic CBD exploration for CBD stones by a single surgical team. Because of the limitations at our institution, all laparoscopic CBD explorations were done via a properly made choledochotomy. Transcystic route was avoided. All patients underwent laparoscopic cholecystectomy in the same sitting. This study was conducted during May 2009 and December 2015.

The series included a total of 31 patients, of which 17 were females and 14 were males. The majority of patients belonged to the age group of 30–55 years. All patients had confirmed choledocholithiasis except one who had a dead worm in CBD by preoperative imaging studies. MRCP was done in a few selected patients due to financial constraints. 4 patients among these, who had failed ERCP, were referred to us by the gastroenterologist. The most common presentation in these patients was right upper quadrant or epigastric pain (13 patients), followed by jaundice or icterus (10 patients) and 6 patients had a history of prior hospitalization due to acute pain in the abdomen, for which they were managed conservatively.

After proper preoperative evaluation and anesthetic clearance, patients were taken up for laparoscopic CBD exploration under general anesthesia. With the patient in supine position, the American technique of laparoscopic cholecystectomy was used. A standard 4-port approach was used with the 10 mm epigastric port 2–3 cm towards the right of the midline so as to have the advantage of easy lavage and suturing of CBD. On a few occasions, an additional 5 mm port was introduced midway between the right hypochondrial and infraumbilical ports so as to aid in the lavage and suction of CBD.

A standard laparoscopic cholecystectomy was done in all cases. Braun clips were used to clip the cystic duct and cystic artery after meticulous dissection of the Calot's triangle. Gallbladder was not lifted off the bed so as to aid in traction during the procedure. Skeltonization of CBD was done up and below with careful dissection. Kocherization of duodenum was done up to the lateral border of inferior vena cava so as to straighten out the CBD. The position of CBD was confirmed by needle aspiration. A longitudinal incision of 1–1.5 cm or equal to the size of the largest stone was made on the CBD. Stay sutures were not given. We avoided the transcystic route because of limitations at our institution [Figure 1]. In most of the patients, the stones were extruded via the choledochotomy by gentle milking with instruments. Stones were also retrieved by Dormia basket [Figure 2] and [Figure 3]. An 8 mm Nephroscope introduced through the epigastric port was used to irrigate the CBD distally with normal saline so as to help in the extrusion of stones. In a few cases, the stones were retrieved with the help of curved Desjardines forceps, and introduced directly through the epigastric wound after removal of epigastric port. This was done to clear the distal CBD.
Figure 1: Choledochotomy

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Figure 2: Removal of worm from CBD

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Figure 3: Removal of stone from CBD

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In some cases, where the stone was impacted high up or far lower down, or the stone was large and impacted and could not be retrieved easily, a 4 mm rigid ureteroscope was introduced through the additional port midway between the right hypochondrial and infraumbical ports for distal stones and through the infraumbical port for upper stones. Stones were fragmented by means of contact lithotripsy using pneumatic lithotripter. CBD was cleared of remaining small segments by forceful saline lavage. Clearance of CBD was confirmed by directly visualizing the lumen of CBD with help of 8 mm Nephroscope introduced through the epigastric port.

For stent placement (11 patients), a guide wire (0.035 inch in diameter) was passed through the side channel of Nephroscope, over which a 7 or 10 French biliary stent was guided into the CBD up to the duodenum across the papilla [Figure 4] and [Figure 5]. The choledochotomy was then closed by interrupted 3-0 vicryl sutures. The gallbladder was now lifted off the liver bed and delivered via the epigastric port.
Figure 4: Placement of guidewire in CBD

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Figure 5: Placement of stent into CBD

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For T-tube drainage, a 14 French T-tube was used. The entire T-tube was placed into the abdomen via the epigastric port [Figure 6]. The tube was then meticulously inserted into the CBD and CBD closed with 3-0 vicryl interrupted sutures. The outlying portion of the T-tube was temporarily clipped so as to avoid the spillage of bile into the peritoneal cavity while the CBD was being sutured. The security of the closure of the tube was tested by temporarily advancing the outlying portion of the tube through one of the 5 mm ports on the right side and injecting normal saline. If there was any leak, it was re-enforced by additional sutures and again tested. The tube was replaced in the peritoneal cavity with the outlying portion clipped so that the 5 mm port is used for handling the gallbladder. The gallbladder was now lifted off the liver bed and delivered via the epigastric port. The outlying limb of the T-tube was brought out through one of the 5 mm ports and fixed after confirmation that the traction on CBD is minimum. In both the groups of patients, an additional tube drain was put in the subhepatic region. Haemostasis was secured, pneumoperitoneum was deflated, and port sites were closed.
Figure 6: Insertion of T-tube with intracorporeal suturing

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  Results Top


Thirty-one patients, who underwent laparoscopic CBD exploration, were studied retrospectively at our institution during May 2009 and December 2015. Eleven patients in the series had stents and 20 had T-tube drainage after CBD exploration. There was no conversion to open nor was there any mortality. The successful clearance of CBD was achieved in 28 patients (90.32%). Three patients (9.67%) who had residual disease were rendered free of the same by postoperative ERCP. The mean operative time was 80 minutes (65–140 minutes). The mean operative time was comparatively less (70–90 minutes) when stents were used after LCBDE as compared to mean operative time (90-110 minutes) in cases where T-tube was used after LCBDE. All patients were kept nil per orally on the day of the operation and liquid orals were started on postoperative day 1. Early ambulation was encouraged. Postoperative pain was reported more in patients with T-tubes, as indicated by the use of analgesics. The mean hospital stay in cases of stents was 2–3 days and 4–7 days in cases of T- tubes. The tube drains kept in the subhepatic space were removed once the output was less than 25 ml/24 h. Twenty-seven patients (87%) had their tube drains removed on the 3rd or 4th postoperative day. Four patients (12%) (1 with stent and 3 with T-tubes) who had persistent drainage of more than 50 ml/24 h had their tube drains removed on the 7th postoperative day. All but 4 patients (7th postoperative day) were discharged from the hospital on the 3rd to 5th postoperative day with proper instructions. All patients were followed up postoperatively on OPD basis at 2 weeks. All stents were removed endoscopically at 3–4 weeks and T-tubes were removed at 4–6 weeks after postoperative T-tube cholangiogram. Patients were then followed for 3 months to 1 year and thereafter annually till December 2015. Two patients (6.45%) with T-tubes had minor biliary leak, which resolved spontaneously on the 7th postoperative day. Port site infection was reported in none. One patient (3%) with T-tube reported on the 8th postoperative day with rise in temperature (102°F). Abdominal ultrasound was done which was suggestive of subhepatic collection. Patient was admitted and the collection was drained by ultrasound guidance; patient was managed conservatively with parenteral antibiotics and discharged from the hospital on the 3rd day of admission. Two patients (6.45%) had transient cholangitis after stent removal, which were managed conservatively with intravenous fluids and parenteral antibiotics. Mild pancreatitis was also reported in 3 patients after stent removal. Stent or T-tube displacement was reported in none. Last, but not the least, patient compliance for the stents was found to be good than T-tubes and the use of stents was found to be cost-effective as well. All these results were comparable with the results published in literature across the globe. Results and complications are depicted in [Table 1] and [Table 2], respectively.
Table 1: Results

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Table 2: Complications

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  Discussion Top


This case series shows that LCBDE can be performed safely, with less morbidity. This is in accordance with the findings of previous studies.[9],[10],[11] Courvoiser, in 1890, showed that indeed the CBD could be cleared at the time of cholecystectomy, nearly 80 years after Langenbech performed the first “open” cholecystectomy.[12] Historically, in patients with CBD stones, surgeons were expected to achieve a clearance rate of CBD of approximately 90% during cholecystectomy. Before 1990, 5–10% failure rate of CBD exploration was documented.[13] Prior to the introduction of laparoscopic CBD exploration, patients with a preoperative diagnosis of CBD stones were managed by a two-stage surgical approach ERCP followed by laparoscopic cholecystectomy.[14] LCBDE has made it possible to avoid the disadvantages of both a two-stage procedure (preoperative ERCP plus laparoscopic cholecystectomy) and the open CBD exploration. With the advent of laparoscopic techniques and instrumentation, recent studies have demonstrated the advantages of laparoscopic CBD exploration as a single stage procedure, with results equivalent to those of ERCP with shorter hospital stay.[15] The risks of sphincterotomy (during ERCP), such as cholangitis and pancreatitis, are significantly reduced because of the preservation of functions of  Sphincter of Oddi More Details, following a laparoscopic CBD exploration. Laparoscopic CBD exploration has also been shown to be cost-effective.[16]

In the hands of a skilled surgeon, laparoscopic CBD exploration and stone extraction remains a safe and valuable alternative. Both transcystic approach and direct choledochotomy methods were used in EAES [7] and Sgourakis trials.[17] The transcystic route remains the route of choice because of lower complications.[18],[19] However, a narrow angulated short cystic duct, low cystic duct, and large >10 mm multiple stones or intrahepatic stones are indications for choledochotomy.[20] In our series, in all patients, CBD exploration was achieved by a properly made longitudinal choledochotomy. Stone clearance was confirmed by visualizing the CBD with Nephroscope. The transcystic route was avoided. Multiple options for the management of choledochotomy following laparoscopic CBD exploration includes primary closure with or without stenting, closure over T-tube, and bilioenteric bypass (in selected patients). In EAES trial T-tube was used in all patients.[7] There is an increasing trend towards primary closure of CBD. Decker et al. in a case series of 100 patients showed that primary closure of CBD is safe and precludes the need for T-tube in all cases.[5] Kim et al. used antegrade biliary stenting using modified biliary stents for biliary decompression as alternative to T-tube.[21] In our series, we used stents in 11 patients and T-tube in 20 patients. Primary closure and bypass was done in none. Extrabiliary drainage was a safe and effective method to prevent biliary leakage or to provide effective biliary decompression in cases of incomplete stone removal after choledochotomy closure in the open cholecystectomy era. Despite these advantages, T-tube related complications were discussed for decades, with 15–28% morbidity either in the open or laparoscopic approach.[22] The most common complications with T-tubes are postoperative cholangitis, accidental T-tube displacement, and biliary leak after removal.[23] Recent studies suggest that laparoscopic endobiliary stents decrease postoperative T-tube related complications, improving patient comfort, and promoting a faster recovery.[24] The main drawback of stenting after laparoscopic CBD exploration is the need for endoscopy postoperatively to remove the stent. In our series of patients in whom stents were used, stents were removed in all patients postoperatively by endoscopy successfully. The presence of residual stones is the second indication for postoperative ERCP. The absence of cannulation failure in ERCP, reported in as many as 20% of the patients with CBD stones, is another advantage of the stenting group that should be taken into account to decide which strategy to use whenever biliary decompression is needed after CBD exploration.[25]


  Conclusion Top


Laparoscopic CBD stenting is a safe method in the treatment of selected patients of CBD stones who need biliary decompression. Because of lower morbidity and shorter hospital stay compared with T-tube drainage, it should be considered as first approach whenever biliary decompression is needed after LCBDE.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Sgourakis G, Karaliotas K. Laparoscopic common bile duct exploration and cholecystectomy versus endoscopic stone extraction and laparoscopic cholecystectomy for choledocholithiasis. A prospective randomized study. Minerva Chir 2002;57:467-74.  Back to cited text no. 17
    
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25.
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

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