Laparoscopic Bile Duct Surgery: Home Truths

In this issue of JMAS, the article by Bandyopadhyay, which are raised by the present publication in JMAS. et al. on 'Antegrade common bile duct (CBD) stenting The important issues regarding the laparoscopic after laparoscopic CBD exploration' [1] makes surgical management of ductal calculi include: (i) interesting reading in addition to raising certain technique of ductal clearance, (ii) need for drainage of unsettled issues concerning this laparoscopic CBD and if so, the best method to achieve this, and procedure. In the first instance, the authors are to be (iii) indications for internal bilio-enteric drainage complemented for the excellent clinical outcome of (choledochoduodenostomy/choledochojejunostomy). their patients treated for ductal calculi with no mortality and a morbidity approximating 6%, which TECHNIQUES OF L APAROSCOPIC DUCTAL is well below that reported in most published series. CLEARANCE Another aspect of the series, which is most interesting The authors of the present series dismiss completely is the low negative endoscopic retrograde trans-cystic duct exploration and indicate that direct cholangiopancreatography (ERCP) rate, 16/316 supraduodenal CBD exploration is preferred in their patients (5%) contrasting with the reported negative institution as it is more reliable. On the basis of my rates varying from 20 to 50%. It is obvious that the own experience and published evidence. authors have very effective protocols for the selection have to disagree with this. In the first instance, of patients requiring ERCP. laparoscopic trans-cystic ductal clearance is infinitely less traumatic than supraduodenal choledochotomy, There is good evidence from one large multi-centre i.e., it leaves the entire extrahepatic biliary tract in its RCT [2] and a smaller single-centre RCT [3] together with pristine state and for this reason, recovery from this many large non-randomized series [4-8] that single stage procedure is almost identical to that of LC alone. [2] It is laparoscopic treatment for patients with symptomatic applicable to about 60% of cases. The size of stone(s) gallstones and ductal calculi is as safe and as effective which can be extracted through the cystic duct as two-stage treatment (endoscopic stone extraction obviously depends on the size of the cystic duct; followed by laparoscopic cholecystectomy), but it although some actually balloon dilate the duct, a I would reduces costs and is kinder to the patients. Nonetheless, the two-stage treatment continues to be the most frequent form of management worldwide. The reasons for this anachronistic situation in this era of evidence-based medicine are several: turf battle and …


Editorial
Laparoscopic bile duct surgery: Home truths

Alfred Cuschieri
Division of Medical Sciences, Scuola Superiore Sant'Anna di Studi Universitari Pisa, Italy Address for correspondence: Alfred Cuschieri, Scuola Superiore Sant'Anna di Studi Universitari Pisa, Italy.E-mail: alfred@acuschieri.com In this issue of JMAS, the article by Bandyopadhyay, which are raised by the present publication in JMAS.

et al. on 'Antegrade common bile duct (CBD) stenting
The important issues regarding the laparoscopic after laparoscopic CBD exploration' [1] makes surgical management of ductal calculi include: (i) interesting reading in addition to raising certain technique of ductal clearance, (ii) need for drainage of unsettled issues concerning this laparoscopic CBD and if so, the best method to achieve this, and procedure.In the first instance, the authors are to be (iii) indications for internal bilio-enteric drainage complemented for the excellent clinical outcome of (choledochoduodenostomy/choledochojejunostomy).their patients treated for ductal calculi with no mortality and a morbidity approximating 6%, which TECHNIQUES OF L APAROSCOPIC DUCTAL is well below that reported in most published series.

Another aspect of the series, which is most interesting
The authors of the present series dismiss completely is the low negative endoscopic retrograde trans-cystic duct exploration and indicate that direct cholangiopancreatography (ERCP) rate, 16/316 supraduodenal CBD exploration is preferred in their patients (5%) contrasting with the reported negative institution as it is more reliable.On the basis of my rates varying from 20 to 50%.It is obvious that the own experience and published evidence. [6,8]uthors have very effective protocols for the selection have to disagree with this.In the first instance, of patients requiring ERCP.laparoscopic trans-cystic ductal clearance is infinitely less traumatic than supraduodenal choledochotomy, There is good evidence from one large multi-centre i.e., it leaves the entire extrahepatic biliary tract in its RCT [2] and a smaller single-centre RCT [3] together with pristine state and for this reason, recovery from this many large non-randomized series [4][5][6][7][8] that single stage procedure is almost identical to that of LC alone. [2]It is laparoscopic treatment for patients with symptomatic applicable to about 60% of cases.The size of stone(s) gallstones and ductal calculi is as safe and as effective which can be extracted through the cystic duct as two-stage treatment (endoscopic stone extraction obviously depends on the size of the cystic duct; followed by laparoscopic cholecystectomy), but it although some actually balloon dilate the duct, a I would reduces costs and is kinder to the patients.Nonetheless, the two-stage treatment continues to be the most frequent form of management worldwide.The reasons for this anachronistic situation in this era of evidence-based medicine are several: turf battle and dominant hold by gastroenterologists, the hassle factor prevalent amongst many surgeons (cannot be bothered to take on the extra work and training entailed) and several unresolved surgical issues regarding the actual intra-operative management, practice, which I do not advocate as it may induce splitting of the duct.Obviously there are cases where trans-cystic duct clearance is not applicable -large stones (>8 mm), occluding stones, excessive stone load in a grossly dilated common bile duct.But in all other instances, the trans-cystic duct clearance (with blind trawling or visually guided through a mini choledochoscope) should be tried first and direct supraduodenal exploration kept in reserve in the event of failure. ) .

NEED FOR DRAINAGE OF THE CBD
There is no need for drainage of the CBD after successful trans-cystic ductal clearance as there is no sutured choledochotomy to protect.Most would drain the CBD after successful supraduodenal choledochotomy to ensure decompression, which reduces the risk of post-operative bile leakage.However, not all agree with this and some close the choledochotomy without drainage. [5]These are brave surgeons as flow debimetry studies have shown that there is indeed a temporary period (several days) of

INDICATIONS FOR BILIO-ENTERIC DRAINAGE
This was considered necessary in 59 patients in the present series (33%).This is higher than expected from reported series in the West.It may of course indicate more severe and advanced ductal stone disease in India.Either way, it does raise the matter of indications for this added procedure, which are not discussed in the reported laparoscopic surgical literature.In my own practice a bilio-enteric by-pass, usually a transection choledochoduodenostomy, is reserved for patients with ducts exceeding 20 mm impaired emptying through the choledochal sphincter and a large stone load.Am I denying some patients the especially after instrumental manipulation inside the possible benefit of bilio-enteric drainage or am I being The question is how?It is my strong belief sensible and cautious?that T-tube drainage should be dropped from surgical laparoscopic bile duct surgical practice as it negates l i c a t i o n s ( w w w .m e d k n o w .c o m l i c a t i o n s ( w w w .m e d k n o w .c o m