Laparoscopic Management of Biliary Stone Disease

Stephen Levinson, MD

Philippe J. Quilici, MD

 

Dept. of Surgery

Dept. of Gastroenterology

Providence Saint Joseph Medical Center, Burbank, CA

In the United States, surgeons perform approximately 600,000 laparoscopic cholecystectomies (LC) per year. LC's have largely superceded open cholecystectomies (OC) as the preferred method of gallbladder removal, accounting for 80% of such procedures in this country. One limitation of LC as compared to OC is the difficulty in dealing with common bile duct (CBD) stones. CBD stones are present in approximately 15% of patients, and are responsible for considerable morbidity and mortality (specifically pancreatitis and ascending cholangitis) which mandates the removal of such stones.

In OC, surgeons can routinely remove CBD stones via common bile duct exploration (CBDE), a natural extension of the operative procedure. In LC however, techniques for detection of CBD stones (intraoperative cholangiography or IOC) and subsequent removal are beset with pitfalls. IOC, performed by injection of dye via a cystic duct catheter placed surgically, adds significant time to the operative procedure. It also requires commitment of additional equipment and personnel to the operating room, and has a false positive rate of stone detection of up to 12%, sometimes resulting in unnecessary CBDE. Furthermore, the finding of stones on operative cholangiogram obligates the surgeon to perform CBDE, either laparoscopic or open . A laparoscopic CBDE is a time consuming, hardware intensive procedure, has a steep learning curve, is associated with up to a 50% failure rate, and risks injury to the CBD. Conversion to open CBDE negates the value of a laparoscopic procedure. Another alternative in patients with stones seen on IOC is to refer the patient postoperatively for ERCP, papillotomy, and stone removal. However, a technical failure rate of up to 15% in some series could lead to a second operative procedure, open CBDE.

A number of researchers have attempted to define parameters which could be useful in preoperative prediction of CBD stones. This includes the presence of any of several parameters: 1) Increased liver enzymes, 2) Preoperative pancreatitis, jaundice, or cholangitis, 3) A dilated CBD or intraductal stone on ultrasound, is predictive of CBD stones 25-48% of the time. Furthermore, stones can be present up to 8% of the time in the absence of such parameters or risk factors. Strategies to deal with possible CBD stones in patients with risk factors are complex. One strategy is to do preoperative ERCP with removal of stones (if present). The problem is that 50-75% of ERCP's performed because of the presence of a risk factor will show no stones. Thus, a large number of unnecessary ERCP's will be performed, with a complication rate of 5-10%, and a technical failure rate of up to 15% (i.e. failure to cannulate CBD). A second strategy is to do IOC on patients with risk factors, and to do intraoperative stone removal if stones are detected. The problem with this, as mentioned is that IOC, is time-consuming and associated with up to 12% false positive rate. Subsequent intraoperative stone removal is both time consuming and risky, and often subjects the patient to an open procedure. A third strategy is to do postoperative ERCP if the IOC shows stones. Again, the problem here is that up to a 15% failure risk associated with ERCP would subject the patient to another surgical procedure to remove the stones.

We have developed a new and simple technique for cholangiography that we believe will largely supplant existing complicated algorithms for dealing with CBD stones. In this laparoscopic technique, in lieu of performing IOC, we secure a standard ERCP catheter (Microvasive, tapered tip) in the cystic duct intraoperatively and leave the catheter in place after surgery.

Postoperatively, all patients undergo a cholangiogram in the x-ray department via the catheter. If no stones are demonstrated, then the catheter is pulled. If stones are present, then the endoscopist performs postoperative ERCP and papillotomy to remove the stones, and then pulls the transcystic catheter.

This technique offers many advantages over existing strategies for dealing with CBD stones. First, ERCP's will be limited only to those patients who have a stone visualized on transcystic cholangiogram. For those surgeons or gastroenterologists who currently stratify patients' need for ERCP according to preoperative risk factors for CBD stones, the TCC approach will eliminate the need to perform ERCP on up to 80% of patients with positive risk factors but who have no stones (False Positives). The ERCP associated complications will thereby be eliminated. Second, the 15% risk of postoperative ERCP failure to cannulate or clear stones (even up to 10% in biliary referral centers) will be largely eliminated by the ability to place a transcystic, transpapillary guidewire. This safety valve will greatly facilitate endoscopic access to the bile duct, eliminate the need for a risky precut papillotomy to gain access to the CBD, and reduce the potential need for a second operation in patients in whom ERCP was a technical failure. Third, the TCC should eliminate the need for IOC and CBDE. Since the TCC/ERCP technique reduces the risks associated with ERCP and optimizes the chance of a successful outcome, the need for IOC and /or CBDE (laparoscopic or open) is greatly reduced (including those CBDE's done for false positive IOC's). Fourth, if this technique is applied to all laparoscopic cholecystectomies, then all CBD stones will be detected including up to 8% of patients who have no preoperative risk factors for stones.