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Laparoscopic Management of Biliary Stone Disease
Management of Choledocholithiasis with a Cystic Duct Catheter
 
Stephen Levinson, MD
Philippe J. Quilici, MD
 
Dept. of Surgery
Dept. of Gastroenterology
Providence Saint Joseph Medical Center, Burbank, CA

 

  Controversies in the Management of CBD Stones

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 LC's have largely superceded open cholecystectomies (OC) as the preferred method of gallbladder removal, accounting for 80% of such procedures in this country.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.

  Using a CDC for a post-operative Cholangiogram

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.

  The LapChole with CDC Placement
bulletOperating Room Setup:Same as Standard LAPCHOLE
bulletHardware: Same as Standard LAPCHOLE
bulletInstruments: Same as Standard LAPCHOLE

Additional Instruments:

bullet1 Blake Drain with drainage reservoir
bullet1 Ureteral 7 French Ureteral Catheter or
bullet1 Fluoro Tip ERCP Cannula Tapered Tip
bullet(210 cm - 5 French 1.7 mm with stainless steel stylet)

Technique

The procedure is initiated as described in the Standard LAPCHOLE Chapter.

1. Inserting the Cystic Duct Cannula in the Intraabdominal Cavity

The cystic duct is exposed and clipped at its junction with the gallbladder with an endoclip. Traction is maintained on Hartmann's pouch to expose the cystic duct. An anterior incision is made with the ENDO SHEARS* instrument.

The cystic duct cannula is inserted via the subxyphoid trocar site. First, the trocar is quickly removed from the subxyphoid site. The site is plugged with a finger and the cannula is inserted bluntly into the intraabdominal cavity under direct vision. When 10 to 15 cm of the cannula is in the intraabdominal cavity, the VERSAPORT* trocar is reinserted bluntly next to the cystic duct cannula. Both the cannula and the trocar are now side by side in the subxyphoid insertion site. The cannula can be advanced, withdrawn and manipulated very easily from the outside of the abdominal cavity.

2. Placing the Cannula in the Biliary Tree

An ENDODISSECT* Instrument or an atraumatic grasper is inserted via the subxyphoid trocar and grasps the tip of the cystic duct cannula. It is inserted into the cystic duct under direct vision and advanced into the common bile duct.

We routinely advance the cannula for about 5-6 cm, and then withdraw the cannula to leave approximately 1.5 to 2 cm inside the cystic duct.

3. Securing the Cannula in the Cystic Duct

The ENDO DISSECT*or grasper is removed from the intraabdominal cavity and replaced with the ENDO CLIP* Applier. It is essential to use a USSC ENDO CLIP* or a SURGICON applier. They are the only instruments that will allow the performance of the next maneuver.

Two clips are placed on the cystic duct. It is essential NOT to close the entire clip around the cystic duct so as not to entirely obliterate the duct and cannula. The partial closing of the clip can only be performed with the USSC ENDO CLIP* applier. ( The Ethicon clip Applier does not have this capability.) Another clip is tightly placed behind the cannula. If using the SURGICON clip applier, only one clip is used on the cannula and behid it.

The ENDO CLIP* applier is now replaced with the ENDO DISSECT* Grasper. The Cannula is grasped outside the cystic duct and pulled .5 cm to check that the cannula is not crushed or locked onto the cystic duct. Then additional cannula is inserted into the intraabdominal cavity to provide slack, so it can be placed laterally to allow for the completion of the laparoscopic cholecystectomy. A Blake Drain is inserted at the end of the procedure.

An intraoperative cholangiogram can be performed. If negative, the cannula is removed. We routinely do not perform an intraoperative cholangiogram. We order it a few hours after the procedure.

  Post-op ERCP

Scenario 1: Choledocholithiasis is demonstrated on the Transcystic Cholangiogram: an ERCP is planned.

ERCP Technique

The cystic duct catheter provides a portal through which a guidewire can be directed into the duodenum at the time of ERCP. The ability to place a guidewire greatly facilitates cannulation of the CBD during ERCP, especially in technically difficult cases.

Equipment

bulletPentax ERCP scope
bulletMicrovasive Ultratome XL
bulletZebra wire
bulletBalloon Retrieval Catheters--8.5 mm. and 11 mm.(Microvasive Extractor XL)
bulletStone retrieval basket

Technique

bulletSTEP 1. A cholangiogram is first performed via transcystic catheter. This helps identify CBD and facilitates cannulation of papilla.
bulletSTEP 2. ERCP is then performed in the standard fashion.
bulletSTEP 3. If cannulation takes longer than 15 minutes, then a 400 cm Zebra wire is advanced through the transcystic catheter and directed by fluoroscopy into the CBD and through the papilla.
bulletSTEP 4. The endoscopist passes a snare through the biopsy channel of the ERCP scope, snares the end of the Zebra wire, and pulls it out of the scope.
bulletSTEP 5. The papillotomy is flushed with saline and advanced over the wire, through the scope, and into position in the papilla and CBD.
bulletSTEP 6. Endoscopist performs papillotomy over the guidewire and removes guidewire/papillotomy assembly.
bulletSTEP 7. The duct is then swept with an 8.5 mm or 11 mm balloon or a stone retrieval basket to remove stone(s).

The transcystic cannula is removed by firmly pulling on it at the bedside or in the ERCP suite. The Blake drain is left in place and the patient is discharged. The Blake drain is then removed a few days later as an outpatient.

NOTE: There has been no reported leak following this protocol. However, the Blake drains are left in place should a bile leak occur.

  Scenario 2: No Common Bile Duct Stone demonstrated.

The Cannula is removed by exerting firm traction. The Blake Drain is left in place and removed 48 hours later as an outpatient.

  Advantages

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.


 
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