Antegrade Common Bile Duct (cbd) Stenting after Laparoscopic Cbd Exploration

may be performed safely in expert hands without mortality and with negligible morbidity. Laparoscopic common bile duct exploration (LCBDE) has been found to be a safe, efficient and cost-effective treatment for choledocholithiasis. choledocholithiasis, laparoscopic common bile duct Following LCBDE, the clearance may be exploration, T-tube drainage ascer tained by a cholangiogram or choledochoscopy. The common bile duct (CBD) may be closed primarily with or without a stent in Laparoscopic common bile duct exploration (LCBDE) situ or may be drained by means of a T-tube or a has been found to be a safe, efficient and cost-effective biliary enteric anastomosis. Materials and treatment for choledocholithiasis.

tackle choledocholithiasis with cholelithiasis.The the operation was 75 min.The mean postoperative hospital stay was 3.5 days.One patient had a minor introduction of laparoscopy postoperative biliary leak.One patient had a right choledocholithiasis as a single stage treatment raised Up to 16% of in treating sub-hepatic collection.Four patients developed postoperative port infection.The stents were removed endoscopically after 4 weeks.Sixty-eight patients could be followed up till 1 year.There has been no incidence of residual disease and the patients on follow-up are asymptomatic.

Conclusion:
In our experience, a single stage laparoscopic treatment of cholelithiasis with choledocholithiasis is a safe, viable and costeffective option.Closure of the CBD over an antegrade stent is a feasible option but requires advanced skills in minimal access surgical techniques, especially endosuturing.The procedure an important issue -how to choose the treatment for each particular patient.
We started performing CBD explorations in 1997.As per our institutional protocol, we have used different modalities to clear the CBD.However, due to the limitations involved in transcystic LCBDE, we have always performed LCBDE through a properly performed choledochotomy.Hereby, we present our experience with antegrade stenting of the common bile duct following LCBDE.) .

MATERIALS AND METHODS
A retrospective study of the patients treated for choledocholithiasis in the period between August 2000 and March 2005 was performed.The specially designed departmental software was utilized to retrieve the data.A single surgical team at our institute performed 5,043 laparoscopic cholecystectomies between August 2000 and March 2005.In the same period, 464 patients with choledocholithiasis were treated at the institute, of whom 22 patients had a primary or a slipped / missed patients underwent a successful clearance of CBD stones [   3].Of the 18 patients with T-tube drainage, 1 patient had bouts of recurrent cholangitis and most patients were clearly unhappy at having a tube from their body.Patients from a rural setting were clearly unwilling to go home with a tube, resulting in their requiring a prolonged hospital stay.These feedbacks played an important role in offering the patients the benefit of stented choledochorrhaphy.
Cincinnati, USA) was placed towards the gallbladder and a nick was created on the cystic duct (CD), which was then cannulated with a 4-5 Fr. ureteric catheter (which had been pre-primed with normal saline to expel possible air bubbles).A clip was then applied on the CD to prevent leakage of contrast material.Ports were withdrawn, the abdomen was deflated and a cholangiogram was obtained with a Digital C arm Fluoroscopy (real time imaging).If a radiolucent shadow was noted, the position of the patient was altered to rule out an air bubble and the entry of contrast material into the duodenum was noted.On of the CBD. the basis of a positive POC, 52 patients underwent A standard 4-port approach was utilized.An optional simultaneous LCBDE with LC. fifth port (5 mm) was introduced midway between the right hypochondrial and umbilical ports to allow The duodenum was then kocherized up to the lateral the introduction of a catheter for lavage or suction border of the inferior vena cava to straighten out the CBD.The position of the CBD was confirmed by needle aspiration with a 24 G needle.The CBD was A standard cholecystectomy was performed then opened longitudinally between 3-0 silk.We have laparoscopically, but the cystic duct was not divided avoided transcystic LCBDE because of its inherent and also the gallbladder was not lifted from the liver limitations [Table 4].bed.Mirizzi syndrome necessitating transaction of the gallbladder at the neck was encountered in nine In most of the patients, the stones were recovered patients.The remnant cuff was subsequently sutured by spontaneous extrusion on choledochotomy or by with 3-0 vicryl sutures.Cholecysto-enteric fistula was gentle milking with the instruments [Figure 1].A 12 found in five patients (cholecystoduodenal -4, Fr.Ryles tube (with its tip cut off) introduced through cholecystocolic -1).The fistulas were isolated during the accessor y 5-mm port was used to perform operation using a combination of sharp and blunt proximal and distal lavage of the common bile duct dissection and fistulectomy was performed with and help in extrusion of the stones.Stones were also scissors.The ensuing rent in the bowel was closed removed by means of a Dormia basket [Figure 2] or a with interrupted 3-0 vicryl sutures in two layers.
Fogarty catheter under choledochoscopic control.In a few patients, curved Per-operative cholangiogram was performed in 69 Desjardines choledocholithotomy forceps were patients.mitations ) .
The cystic duct was then divided and the gallbladder was then lifted up from the liver bed and removed with the extracted stones in an endobag.Hemostasis was secured, a subhepatic drain was placed and the abdomen was deflated.

RESULTS
In the time period between August 2000 and March 2005, 100 patients under went antegrade CBD stenting following LCBDE at our institution.
The median duration of the operation was 75 min (55-155) min.Early oral intake and early ambulation was encouraged.Most of the patients were allowed to have liquids on the day of the operation and were ambulatory the next day.The mean postoperative hospital stay was 3.5 days (2-7 days).The intraabdominal subhepatic drains were removed once the output was less than 20 ml/day.By the third postoperative day, all but one patient had their drains removed.The patients with cholecysto-enteric fistula were allowed oral intake from the third postoperative day.In patients with impacted stones in the CBD or common hepatic duct, a rigid ureteroscope introduced through an additional subxiphoid port (5 mm) for lower CBD or through the umbilical port for upper CBD, was used to fragment the stones by means of intracorporeal contact lithotripsy using a pneumatic lithotripter.The sediments were then There was no conversion in the series nor was there any mortality.After discharge, the patients were followed up at 1week, then monthly for 2 months and subsequently were asked to come for annual checkups for 2 years.The stent was removed endoscopically after 4 weeks at the first monthly visit.
One patient had a minor biliary leak via the drainage tube, which stopped spontaneously on the fifth postoperative day and the tube could be removed ) .
on the sixth postoperative day.Four patients developed port infection, which was controlled with antibiotics.A male patient who had a cholecystoduodenal fistula reported with fever after 2 weeks.Abdominal ultrasonogram showed a rightsided subhepatic collection, which yielded pus on guided aspiration.The collection was fully aspirated and the patient was admitted and treated conservatively with parenteral antibiotics.He had an otherwise uneventful recovery.
2] Following the principles of open surgery, a surgeon has multiple options regarding the management of choledochotomy following LCBDE: � Primary closure with / without an antegrade biliary stent [8,[13][14][15] � Closure over a T-tube [15][16][17][18][19] � Bilio-enteric bypass (in indicated patients) [19,20] In this study period of LCBDE, it was nearly 2 years associated with hypokalemia was encountered in a before we attempted closure of choledochotomy with 71-year-old diabetic male patient.The ileus resolved an antegrade biliary stent.This happened once we on the fifth postoperative day and the patient was started performing completion choledochoscopy for discharged the next day.
confirmation of CBD clearance.Post-exploratory cholangiogram was found to be technically The stents were removed endoscopically after 4 weeks cumbersome, with false interpretation due to leaks in all the patients.The follow-up protocol at our and air bubbles.institute entails postoperative checkups at the end of the first and the fourth week.Similar protocol of In the initial period, a CBD dilated beyond 1.5 cm removal of stent at 4 weeks after operation was was treated with a choledocho-enteric anastomosis, followed by Isla Griniatos and Wan at Ealing Hospital, while T-tube drainage was performed in the undilated Selectively, ERCP was performed at stent ones.The presence of a T-tube is associated with a removal to assess the status of the CBD.One patient few known disadvantages -patient discomfort, an had transient cholangitis following stent removal, increased hospital stay, delayed recovery, tube which was controlled with parenteral antibiotics.All displacement / dislodging, but 17 patients were followed up regularly till the fragmentation, to name a few. [21]This led us to think third postoperative month.Follow-up till the first year about offering alternative options to our patients.could be completed in 68 patients.There has been Our experiences at transcystic exploration were also no incidence of residual disease and all the patients not encouraging.In two patients in whom we who were in regular follow-up have been attempted a transcystic CBD exploration, a change asymptomatic.
of operative approach to choledochotomy was precipitated as we failed to achieve CBD clearance DISCUSSION through cystic duct.The ease of direct CBD exploration and our failure with transcystic London. [7]fection and LCBDE is now a frequently performed operation by surgeons experienced in advanced minimal access surgeries.LC with LCBDE could be performed as a single stage procedure in a large series. [8]LCBDE has been shown to be as effective as endoscopic stone removal with lesser procedural time and shorter hospital stay. [9]This allows the preservation of the functions of sphincter of Oddi and thus does away with the risks of cholangitis, pancreatitis and, as a long-term possibility, malignancy, etc, following a sphincterotomy.It has also been shown to be a more approaches led us to follow a protocol of laparoscopic CBD exploration as has been described in this article.][27] Unfortunately, two out of the four patients in whom we attempted primary closure of the CBD developed bilioma in the immediate postoperative period and re-laparoscopy had to be done, where leak was found from the ) .
Bandyopadhyay et al.: CBD stenting after laparoscopic exploration choledochotomy site in both the patients and was subsequently closed over a T-tube.This experience prevented us from attempting any other primary closure of unstented CBD.
Report of an animal study published earlier [28] led us to conceptualize closure of the CBD over an antegrade biliary stent.The first report of laparoscopic primary closure of the CBD had come from Lange V and his team. [29]e had started performing choledochoscopies followed by antegrade biliary stenting by then.The initial experiences (8 patients

CONCLUSION
A single stage laparoscopic treatment of cholelithiasis with choledocholithiasis has been found to be safe, -5 female and 3 male) over a 3-month period were viable and cost-effective.Closure of the CBD over an encouraging and we persisted with the technique.
antegrade stent after LCBDE is a feasible option but requires advanced skills in minimal access surgical Recently, modified plastic biliary stents (af ter techniques, especially endosuturing.Endoscopic removing the proximal flap) have also been used [30] removal of the stent after a safe interval of 4 weeks and there have been more reports describing the does not result in significantly added morbidity and success of this procedure, [31,32] which had been already cost of the treatment procedure.found to be a preferred technique in animal experiments as well. [33]We however do not remove The experience of our first hundred patients where In these days of evidence-based incidence, we have   ) .
hundred patients had undergone post-exploratory antegrade biliary stenting with closure of CBD on the stent [Table : Small cystic duct diameter Low common bile duct cystic duct junction Obstructive valves in cystic duct Contraindications: Large multiple stones in common bile duct Stones in upper common bile duct Complications Common bile duct perforation Common bile duct avulsion cleared by means of forceful saline lavage.Confirmation of CBD clearance was done by postexplorator y cholangiogram in 32 patients and choledochoscopy in 130 patients.Completion choledochoscopy was performed by means of a pediatric bronchoscope (Pentex FB-15P).Following this, a guide wire was then passed through the side channel of the bronchoscope over which a 7 Fr, 10 cm double-flap biliary stent was guided into the CBD up to the duodenum across the sphincter.The CBD was then closed by interrupted 3-0 vicryl sutures.

Figure 1 :
Figure 1: Stone being delivered from CBD by gentle milking

Figure 2 :
Figure 2: Stone being delivered from CBD by a Dormia basket 2. Urbach DR.Khajanchee YS, Jobe BA, Standage BA, Hansen PD, an antegrade biliary stent had been used as an Swanstrom LL.Cost-effective management of common bile duct stones: A decision analysis of the use of endoscopic retrograde adjunct to CBD closure has been encouraging.There cholangiopancreatography has been no conversion or mortality.The incidence cholangiography and laparoscopic bile duct exploration.Surg and complication has been minimal [Table 5].Endosc 2001;15:4-13 3. A prospective analysis of 1518 laparoscopic cholecystectomies.The Southern Surgeons Club.N Engl J Med 1991;324:1073-8.

�
4. Curet MJ, Pitcher DE, Marit DT, Zucko KA.Laparoscopic antegrade sphincterotomy: A new technique for the management of complex instituted a protocol according to which our patients choledocholithiasis.Ann Surg 1995;221:149-55.having choledocholithiasis with cholelithiasis are 5. Rojas-Ortega S, Arizpe-Bravo D, Marin lopez ER, Cesin-Sanchez R, treated.The principles of the protocol include the Roman GR, Gomec C. Transcystic common bile duct exploration in the management of patients with choledocholithiasis.J Defined indications for preoperative ERCP [

Table 2 ]
. Sixteen patients with a negative ERCP underwent laparoscopic cholecystectomy (LC) only.There were 38 ERCP failures due to various reasons [Table2].These patients subsequently underwent LCBDE.Of the 22 patients with post-cholecystectomy

Table 1 : Institutional protocol for management of while laparoscopic choledocho-enteric anastomosis cholelithiasis with choledocholithiasis was performed Institutional protocol for management of cholelithiasis with in 59 patients choledocholithiasis Table 2: Break up endoscopic retrograde cholangiopancreatography group
� Multiple large calculi: 15 (39.4%) � Failure to cannulate: 9 (23.

Table 3 : Laparoscopic common bile duct exploration flow chart
Bandyopadhyay et al.: CBD stenting after laparoscopic exploration

Table 6 .
Petelin JB.Laparoscopic common bile duct exploration.Surg Defined indications for LC with LCBDE [Table 1] � LCBDE performed via choledochotomy directly.Transcystic LCBDE was avoided because of inherent limitations and possible contraindications / complications [Table 4] � Choledocho-enteric anastomosis is performed after LCBDE if CBD diameter is >1.5 cm � All other patients undergo closure of choledochotomy with an antegrade biliary stent, which is removed endoscopically after 4 weeks.