At present, the combination of three mirrors (laparoscopy, choledochoscopy and duodenoscopy are the main means of minimally invasive treatment of gallbladder stones combined with common bile duct stones through a series of sequential treatment protocols with complementary advantages).
However, the combination of these three mirrors is different in different hospitals and different doctors, and currently there are three main options.
1, duodenoscopy + laparoscopy.
2, laparoscopy + choledochoscopy.
3, duodenoscopy + laparoscopy + choledochoscopy.
So, which is the first program, 1 or 2 or 3? We know that each surgery has its own surgical indications, the most consistent with the indications is the first program, let’s look at these three programs are the indications for surgery?
1, duodenoscopy + laparoscopy: for extrahepatic bile duct stones without bile duct strictures in combination with gallbladder stones. Treatment is divided into two stages: firstly, duodenoscopic lithotripsy is applied, including endoscopic retrograde cholangiopancreatography (ERCP), Oddi sphincterotomy (EST), duodenal papillary dilatation, lithotripsy basket, lithotripsy basket, lithotripsy balloon, built-in nasal bile duct (ENBD) drainage and other comprehensive treatment, and 2-3 days after successful lithotripsy, if the patient has no obvious contraindications to surgery, If there is no obvious contraindication to surgery, laparoscopic cholecystectomy (LC) is performed again, all using the three-hole method, so that the disease is completely cured.
If complications such as acute pancreatitis or duodenal perforation occur during the application of duodenoscopy for choledocholithiasis, LC will be performed after treatment and stabilization of the disease, which not only maintains the integrity of the biliary system, but also divides the complex operation into two steps, reducing the difficulty of the operation and improving the safety of the operation.
2.Laparoscopy + choledochoscopy: It is suitable for patients with failed endoscopic lithotripsy, failed ENBD, or intraoperative suspected intra- and extra-hepatic bile duct stones, and the diameter of dilated common bile duct is greater than 1.2 cm. If there is no dilatation of the common bile duct or if the common bile duct is slender, open surgery will be performed. The treatment procedure: laparoscopic exploration of the common bile duct was performed with a four-hole approach; four methods were combined to remove the stones (direct extraction with instruments, water flushing, choledochoscopy, and intraoperative fluid electrolysis); after choledochoscopy, a T-tube was left in place for drainage.
If there is no stone left, the T-tube will be removed after 3 weeks. Although the postoperative hospital stay is slightly longer, this option still retains the advantages of minimally invasive treatment compared with open surgery: high success rate, less postoperative pain, and faster recovery of gastrointestinal function.
3.Duodenoscopy + laparoscopy + choledochoscopy: It is suitable for patients who have failed duodenoscopy but can complete ENBD treatment, and the diameter of dilated common bile duct is greater than 1.2cm. If there is no dilatation of the common bile duct or if the common bile duct is slender, open surgery will be performed. Treatment procedure.
(1) Endoscopic treatment stage: After successful ERCP, if it is determined that it is difficult to remove the stones in the bile duct via endoscopy, effective ENBD catheter drainage treatment is performed.
(2) Laparoscopic treatment stage: After the condition is stabilized for 1 to 2 days, laparoscopic common bile duct exploration is performed to remove the bile duct stones, all using the four-hole method, and then the ENBD catheter is left in the common bile duct after cholangioscopic examination to confirm that no stones remain, and the common bile duct incision is closed in one stage.
(3) Postoperative treatment: The catheter can be removed if there is no abnormality after 4-5 days of postoperative imaging by ENBD catheter. This protocol achieves the best combination of the three minimally invasive techniques and makes a qualitative leap in minimally invasive treatment results. The ENBD catheter is first placed endoscopically to reduce the biliary pressure and relieve the systemic condition; the ENBD catheter is placed in the common bile duct during laparoscopy to close the biliary incision in one stage and maintain the integrity and normal physiological function of the biliary system; the postoperative ENBD catheter replaces the supporting drainage of the T-tube, avoiding the complications associated with the placement of the T-tube and significantly shortening the postoperative hospital stay.
Several additional issues need to be understood.
1. Is duodenoscopy or laparoscopy combined with choledochoscopy preferred for the treatment of common bile duct stones?
There is still controversy. Endoscopists prefer the former, while surgeons believe that duodenoscopic choledocholith extraction has more complications, such as pancreatitis, intestinal perforation, bleeding, etc. Moreover, the papillary Oddi sphincter of the duodenum needs to be cut, which may destroy the physiological structure of the normal biliary system and lead to long-term complications such as reflux cholangitis and biliary stenosis, therefore, laparoscopy combined with choledochoscopy should be considered as a priority for minimally invasive stone extraction. Since both duodenoscopy and laparoscopy are operated by surgeons, we have a deeper understanding of the advantages and disadvantages of both options. Based on our experience, we believe that duodenoscopic lithotripsy should be given priority.
In comparison, duodenoscopic lithotripsy causes less damage to the patient and can be used to treat patients with inflammatory stenosis of the duodenal papilla at the same time. Moreover, with the advancement of technology and proficiency, complications after treatment with duodenoscopy are becoming less frequent. In addition, since the degree of sphincter of Oddi incision is controlled as much as possible, the function of the sphincter of Oddi is preserved as much as possible by advocating small papillary incision and large dilatation, so that serious symptoms caused by complications such as reflux cholangitis in the long term are not often observed clinically.
2.How long is it good to perform laparoscopic surgery after duodenoscopy?
After duodenoscopic treatment, the operation of Oddi sphincter incision, stone extraction and placement of ENBD tube drainage may lead to edema and inflammatory adhesions in the triangle of gallbladder and common bile duct, which makes laparoscopic operation more difficult. This pathological change gradually worsens with time. According to the literature and our experience, laparoscopic surgery should be performed early 1 to 2 days after duodenoscopic treatment if there are no serious complications related to endoscopic treatment.
At this time, local edema and adhesions are mostly not serious, which reduces the difficulty of surgery to some extent. In addition, we should pay attention to the indication role of nasobiliary ducts in LC surgery, and it is better to place ENBD ducts in the right hepatic duct after ERCP, especially when the gallbladder triangle is difficult to dissect due to inflammation, ENBD ducts can play a good indication role, which makes the operator more confident when dissecting the cervical duct of the gallbladder, avoiding intermediate open abdomen and increasing the success rate of LC; at the same time, the damage to the right hepatic duct, common hepatic duct and common bile duct can be Early detection and early treatment.
3.Do I still need to keep a T-tube in the duodenoscopy+laparoscopy+cholangioscopy program?
The risk of bile leak and biliary stricture is reduced because the nasobiliary duct has been successfully placed endoscopically and can act as a support drainage in the bile duct. Therefore, we do not place a T-tube for those who have been determined to have a clean stone and no biliary stricture during the operation, and use 3-0 absorbable thread to close the common bile duct in one stage. This not only reduces the patient’s pain, but also shortens the hospitalization time and reduces the treatment cost.