Laparoscopic cholecystectomy (LC) is the gold standard treatment for symptomatic cholecystolithiasis. The most appropriate management of concurrent common bile ductal stones (CBDS) in the elective setting, however, remains controversial. CBDS are present in approximately 10–15% of patients undergoing cholecystectomy for symptomatic gallstones [
The improved laparoscopic skill and the development of dedicated laparoscopic instrumentation have offered the opportunity to treat gallstones and CBDS laparoscopically during the same session. This option, which has been introduced since more than 20 years into routine surgical practice and has become routine in a few centers, has proven to be a safe and effective alternative to the sequential endolaparoscopic approach. The EAES clinical trial comparing LC and common bile duct exploration (LCBDE) versus ERCP with endoscopic sphincterotomy (ES) followed by LC in fit patients (American Society of Anesthesiologists (ASA) grades I and II) has proven the two approaches to be equally effective but with a shorter hospital stay after the single-stage approach [
The patients presenting gallbladder stones and secondary CBD stones were treated according to the authors’ previously published algorithm and surgical technique (Figure
Treatment algorithm for patients undergoing laparoscopic cholecystectomy with intraoperative cholangiography. LC: laparoscopic cholecystectomy. IOC: intraoperative cholangiography.
Out of 121 cases, 61 patients who were elderly at the time of surgery had passed away for unrelated causes but were declared free from biliary symptoms from their relatives. Fourteen patients (11.5%) were lost to follow-up. The 46 remaining patients from the original series underwent the follow-up protocol (17 males and 29 females were examined; mean age was 76.4 years, range 45–92 years), with a medium follow-up of 17.1 years (range 12.6–22.7 years).
Specific symptoms of bile stasis occurred in one (2.1%) female patient presenting with episodes of cholangitis that occurred sixteen years after LC + LCBDE. Two more (4.3%) male patients reported dyspepsia. Biochemistry was negative in all patients except for the patient with cholangitis who showed increased levels of alkaline phosphatase,
Results of medium 17 years’ follow-up (12.6–22.7 years).
Patients, |
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Unrelated death, |
61 (50.4) |
Lost at follow-up, |
14 (11.5) |
Available patients’ data, |
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Symptomatic patients, |
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Cholangitis | 1 (2.7) |
Dyspepsia | 2 (5.4) |
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Biochemical biliary stasis, |
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US evaluation, |
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Stones | 0 (0) |
Stricture | 0 (0) |
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MRI, |
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Stones | 1 (2.1) |
Ductal dilatation | 1 (2.1) |
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Ductal stones’ recurrence, |
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ERCP, |
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CBD stricture, |
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Aim of this study is to report the longer-term results with a medium follow-up of 17 years in a consecutive series of unselected patients who underwent laparoscopic choledochotomy with T-tube biliary drainage. Complete follow-up data, including physical examination, laboratory exams, and imaging data, were obtained in the 46 patients who were available at the time of the follow-up call. Sixty-one patients had passed away for other reasons since many of them were already older than 65 years of age at the time of surgery [
Single-stage laparoscopic treatment of gallstones and CBD stones has been adopted by few dedicated centers [
In the authors’ opinion, laparoscopic transcystic duct exploration should be the technique of choice because it is less invasive. Laparoscopic choledochotomy should be reserved to patients in whom transcystic duct exploration is not possible or when intraoperative cholangiography shows the presence of unfavorable conditions for a transcystic duct approach. The ideal indications for the transcystic duct approach have been clearly defined: (a) a dilated cystic duct, joining the CBD on its lateral side; (b) a limited number of ductal stones (<4); (c) small size of ductal stones located in the CBD [
Patients who undergo a choledochotomy are generally considered to be at greater risk of long-term morbidity, namely, stricture, also up to twenty years after surgery as reported after open surgery [
In the authors’ series, a T-tube drainage was employed routinely after laparoscopic transverse choledochotomy because the aim was to evaluate the safety and efficacy of this (by that time) new procedure, particularly in terms of residual stones’ rate. Later, the indications for T-tube placement were reviewed and now it is employed selectively only in case of intraoperative instrumental manipulation of the papilla, such as transpapillary passage of basket or choledochoscope. Several other complications related to the use of T-tube biliary drainage are reported in the literature and include fluid electrolyte imbalance, sepsis, premature dislodgement, bile leak, biliary peritonitis, prolonged biliary fistula, and late biliary stricture [
The main criticisms against laparoscopic single-stage treatment of gallstones and CBD stones are related to purported higher costs, the need for advanced laparoscopic biliary expertise, and the fact that the operative time for LC with LCBDE may not be foreseen in every case. The cost of LC with LCBDE has been reported by several authors to be lower than for the two-stage approach [
In conclusion, in the authors’ opinion LCDBE during LC should be the treatment of choice in elective patients with gallstones and CBD stones in centers where adequate expertise and a dedicated instrumentation are available. This procedure should be performed by a laparoscopic transcystic duct approach whenever possible and by transverse choledochotomy in selected cases. Laparoscopic transverse choledochotomy during LC has proven to be safe and effective also at longer-term follow-up, with no evidence of common bile duct stricture and with a stones’ recurrence rate that is much lower than that reported in the literature after endoscopic sphincterotomy. For good results to be achieved, the choledochotomy must be performed with a correct surgical technique aimed at preventing the occurrence of ischemia, with a T-tube of small diameter, which is left in place long enough for a mature sinus tract to develop, so as to avoid the occurrence of bile peritonitis after biliary drainage removal.
Silvia Quaresima, Andrea Balla, Mario Guerrieri, Giovanni Lezoche, Roberto Campagnacci, Giancarlo D’Ambrosio, Emanuele Lezoche, and Alessandro M. Paganini have no conflict of interests or financial ties to disclose.