Page 13 - World Journal of Laparoscopic Surgery

Dennis L Sta Ana

add to this, standard algorithm, variations in laparoscopic skills, laparoscopic choledochotomy and delayed ERCP/ES for
availability of proper equipment and cost differences in medical patients with failed LTCCBDE, showed no significant
centers perpetuate the lack of consensus for this problem. The difference in clearance rate, morbidity and length of hospital
current practice option for CDS at the time of laparoscopic stay.
cholecystectomy (LC) are preoperative or postoperative ERCP/ 4. A. LTCCBDE: Transcystic common duct exploration using
ES, intraoperative ERCP/ES, LTCCBDE, LCBDE and outright dormia basket, fogarty catheter affords the patient with
open CBDE. In the absence of official consensus, decision CDS a single stage removal of the gallbladder and the
becomes dependent on the patient’s medical fitness, technical common duct stone without t tube insertion. Success
skill of the surgeon, availability of equipment, availability of the rate is about 80%. 15-17,14,18,19 In cases of failure a choice
endoscopic team and cost. between LCBDE, Intraoperative endoscopic removal of
stone or postoperative stone extraction may be made.
RESULTS AND DISCUSSION B. LCBDE: A less attractive choice than LTCCBDE, it
entails a choledochotomy to extract the CDS. It demands
The most contentious issue in the management of CDS is which excellent skills and more operative time than the other
between laparoscopic surgery and ERCP will be most beneficial surgical options. Success rate ranges from 50 to
to patients. Two RCTs conducted comparative studies on 97%. 14,15,20
preoperative ERCP and laparoscopic CBDE using a total of 378
6,7
patients (Table 1). Two smaller RCTs compared treatments of Complications for ERCP
stones found during surgery using 166 randomized patients
8,9
(Table 2). Conversion rates for laparoscopic surgery were 1. ERCP/ES complication
5
9
8
7
7.4%, implied 3.5%, 2.4% and 1.3%. Combined success rates 2. Pancreatitis (8%)
for laparoscopic vs endoscopic CBD stone clearance on an 3. Bleeding (3%)
intention-to-treat basis were 88% vs 88% for the preoperative 4. Perforation (1.5%)
ERCP comparison. And for intraoperatively discovered CDS, 5. Cholangitis (2%)
there is 84% success rate for laparoscopic stone clearance as 6. Recurrent stones (8%)
compared to 75% in the postoperative ERCP. Success rates for 7. Stenosis (8%).
transcystic clearance is 81% and 85% choledochotomy. 6-9
Furthermore, the meta-analysis for laparoscopic stone clearance List of Complications for Laparoscopic
Cholecystectomy
and both preoperative and postoperative ERCP showed no
significant difference mortality, morbidity, success rate in ductal 1. Wound infection (7.5%)
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clearance, and hospital stay except for the study of Rhodes 9 2. Bleeding (0.5%)
wherein the single stage approached was significantly shorter. 3. Abscess (0.15%)
It is noteworthy, however, that the endoscopy arm is an 4. Postoperative bile leak (0.75%)
extraprocedure during the treatment process. 5. Pulmonary embolism (0.5%)
1. Open CBDE: In a systematic review by Martin DJ et al, 6. Pneumonia, pulmonary(0.2%)
2006(11),open surgery result showed lower failure of 7. Urinary (0.2%)
treatment with fewer additional procedures. It also showed 8. Cardiac (0.2%)
less mortality if compared with ERCP/CS.This procedure 9. Retained stones (0.2%).
poses clear clear discomfort to the patient. In addition,the
authors cautioned that the data are little dated and modern Patient Selection
practice context must be kept in mind. Age seems to be important in predicting the incidence of CDS.
2. Preoperative ERCP/ES: ERCP has the ability to remove Under the age of 60, patients with gallstones have 8 to 15%
21
CDS in 90% of cases. However, patients with clinical and chance of concomitant CDS and in patients over 60 years,
biochemical suspicion of CDS, only 20-50% will be truly concomitant CDS is 15 to 60%. 1
positive after ERCP. The patient, therefore, is unnecessarily Atherosclerotic heart disease is not an absolute contra-
exposed to complications of ERCP which runs to 5-20% 11- indication in laparoscopic CDS clearance. 22-24 Circumstantial
13 as well as delayed the treatment and resultant additional factor such as inadequate expertise in laparoscopic procedure
cost. On the other hand, in cases where there is high pretest may result in prolonged surgery with prolonged
probability of CDS and in the absence of expertise, this pneumoperitonium thereby possibly increasing the intracranial
procedure becomes the most cost effective strategy. 1 pressure (ICP). Prolonged pneumoperitoneum in the
3. ERCP/ES after LC. In patients with CDS discovered during background of increased ICP is a contraindication for
LC, endoscopic stone clearance may be performed in another laparoscopy 23-25 hence clinical situation dictates preoperative
day. Reason may be due to lack of expertise to do a single stone extraction or the use of open CBDE to remove the CDS.
stage surgery or absence of an endoscopist. A focused CDS in the background of acute cholecystitis is seen in 3 to
26
8
study by Nathanson et al. 2005 comparing single stage 25% of patients. When considering LTCCBDE, the surgeon
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