Posted on

cbd stone removal surgery

Two trials assessed LC + LCBDE versus LC+post-operative ERCP. There was no reported mortality in either of the groups. There was no significant difference in the morbidity between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 13/81 (16%) versus 12/85 (14%) OR 1.16; 95% CI 0.50 to 2.72). There was a significant difference in the retained stones between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 7/81 (9%) versus 21/85 (25%) OR 0.28; 95% CI 0.11 to 0.72; P = 0.008.

Open bile duct surgery seems superior to ERCP in achieving common bile duct stone clearance based on the evidence available from the early endoscopy era. There is no significant difference in the mortality and morbidity between laparoscopic bile duct clearance and the endoscopic options. There is no significant reduction in the number of retained stones and failure rates in the laparoscopy groups compared with the pre-operative and intra-operative ERCP groups. There is no significant difference in the mortality, morbidity, retained stones, and failure rates between the single-stage laparoscopic bile duct clearance and two-stage endoscopic management. More randomised clinical trials without risks of systematic and random errors are necessary to confirm these findings.

Between 10% to 18% of people undergoing cholecystectomy for gallstones have common bile duct stones. Treatment of the bile duct stones can be conducted as open cholecystectomy plus open common bile duct exploration or laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC + LCBDE) versus pre- or post-cholecystectomy endoscopic retrograde cholangiopancreatography (ERCP) in two stages, usually combined with either sphincterotomy (commonest) or sphincteroplasty (papillary dilatation) for common bile duct clearance. The benefits and harms of the different approaches are not known.

Sixteen randomised clinical trials with a total of 1758 randomised participants fulfilled the inclusion criteria of this review. Eight trials with 737 participants compared open surgical clearance with ERCP; five trials with 621 participants compared laparoscopic clearance with pre-operative ERCP; and two trials with 166 participants compared laparoscopic clearance with postoperative ERCP. One trial with 234 participants compared LCBDE with intra-operative ERCP. There were no trials of open or LCBDE versus ERCP in people without an intact gallbladder. All trials had a high risk of bias.

There was no significant difference in the mortality between open surgery versus ERCP clearance (eight trials; 733 participants; 5/371 (1%) versus 10/358 (3%) OR 0.51;95% CI 0.18 to 1.44). Neither was there a significant difference in the morbidity between open surgery versus ERCP clearance (eight trials; 733 participants; 76/371 (20%) versus 67/358 (19%) OR 1.12; 95% CI 0.77 to 1.62). Participants in the open surgery group had significantly fewer retained stones compared with the ERCP group (seven trials; 609 participants; 20/313 (6%) versus 47/296 (16%) OR 0.36; 95% CI 0.21 to 0.62), P = 0.0002.

Background
Gallstones are a common problem in the general population and commonly cause problems with pain (biliary colic) and gallbladder infections (acute cholecystitis). Gallstones can sometimes migrate out of the gallbladder and become trapped in the tube between the gallbladder and the small bowel (common bile duct). Here, they obstruct the flow of bile from the liver and gallbladder into the small bowel and cause pain, jaundice (yellowish discolouration of the eyes, dark urine, and pale stools), and sometimes severe infections of the bile (cholangitis). Between 10% and 18% of people undergoing cholecystectomy for gallstones have common bile duct stones.

Two review authors independently identified the trials for inclusion and independently extracted data. We calculated the odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI) using both fixed-effect and random-effects models meta-analyses, performed with Review Manager 5.

Review questions
We analysed results from randomised clinical trials in the literature to assess the benefits and harms of these procedures

We included all randomised clinical trials which compared the results from open surgery versus endoscopic clearance and laparoscopic surgery versus endoscopic clearance for common bile duct stones.

Open CBD exploration

There is no consensus regarding the ideal management of concurrent gallbladder and common bile duct (CBD) stones. Currently the treatment protocol involves most commonly a sequential approach consisting of endoscopic sphincterotomy followed by laparoscopic cholecystectomy or a single stage laparoscopic procedure, including cholecystectomy and exploration of the CBD. For this article literature search was performed using online search engines, Google, Pubmed, the online Springer link library and the Cochrane Database Systematic Review. Review articles, prospective and retrospective studies which detailed or compared the various treatment strategies for CBD stones were selected and analyzed. This review article aims to provide an insight into the optimal management of CBD stones in different clinical scenarios. Endoscopic sphincterotomy has inherent morbidity and complications like CBD stone recurrence whereas laparoscopic CBD exploration demands considerable expertise which is available only at specialized centres. The clinical presentation of the patient, number of stones, size of CBD, available resources and technical expertise at hand are an important consideration for the ideal management in different scenarios.

Management Options

Ahmed et al. [10] compared preoperative versus intraoperative endoscopic sphincterotomy for management of CBD stones. 198 patients diagnosed preoperatively with gallbladder and CBD stones were eligible. They were randomly divided into two groups: Preoperative endoscopic Sphincterotomy (PEST)/LC group (n = 100) and LC/Intraoperative endoscopic Sphincterotomy (IOEST) group (n = 98). The operative duration, surgical success rate, number of stone extracted, postoperative complications, retained common bile duct stones, and postoperative lengths of stay were compared prospectively. There were no statistically significant differences in surgical time, surgical success rate, CBD diameter, stone size, or stone number between the two groups. The success rate was 95.3 % and 97.8 % for PEST/LC and LC/IOEST, respectively. There were no significant difference in postoperative retained stones, surgical time, and complications, but the total hospital stay was significantly shorter in the LC/IOEST group. They concluded that PEST/LC and LC/IOEST are both good options for dealing with preoperatively diagnosed CBDS, but when there is enough experience and facilities, LC/IOEST, as a single-stage treatment, should be preferable.

Introduction

The preoperative evaluation for CBD stones should include a careful history, biochemical tests and abdominal ultrasonography. It seems reasonable to avoid further diagnostic preoperative investigations and routine intraoperative cholangiography in patients with absence of jaundice, normal liver function tests, and ultrasonographic evidence of a normal biliary tree (CBD diameter <9 mm) even in the presence of a recent acute Cholecystitis [11].