Since Stoker et al. successfully completed the first laparoscopic cholecystectomy with exploration of the common bile duct in 1991, the treatment of gallbladder combined with common bile duct stones has undergone a qualitative change. With the popularization of minimally invasive surgery in China and the improvement of minimally invasive surgical equipment, the surgeon’s philosophy has also changed. At present, there are two main minimally invasive treatment modalities for gallbladder stones combined with common bile duct stones.
One is the application of laparoscopy plus choledochoscopy.
The second is laparoscopy plus duodenoscopy.
There are still many controversies about the choice of the two treatment modalities. How to choose the best treatment method with few postoperative near and long-term complications, low mortality and low clinical costs is a problem that needs to be faced frequently in clinical practice. This paper provides a brief review of the choice of surgical options for the combined treatment of gallbladder and common bile duct stones with three scopes.
I. Indications for laparoscopy plus choledochoscopy and laparoscopy plus duodenoscopy
1.Laparoscopy plus choledochoscopy
The indications for laparoscopy plus choledochoscopy in the treatment of gallbladder stones combined with common bile duct stones are: common bile duct diameter of 0.8 cm or more; repeated application of duodenoscopy for stone extraction failure, LC+LCDE can be selected for stone extraction. There are two methods of biliary exploration: one is exploration through the biliary cystic duct; the other is exploration directly through the common bile duct. After biliary duct exploration, the common bile duct can be closed without opening it and absorbable clips can be applied directly after stone extraction, which is a simple procedure and less likely to cause biliary strictures.
After common bile duct exploration, there are two ways to deal with common bile duct stones: one is to place a T-tube after cholecystectomy and common bile duct exploration; the other is to perform stage I suturing after cholecystectomy and common bile duct exploration. Stage I suture requires patency of the lower end of the common bile duct, mild inflammation and no residual stones; skilled microscopic suturing technique, and sutures require the application of absorbable sutures.
2.Laparoscopy plus duodenoscopy
The laparoscopy plus duodenoscopy can be chosen for gallbladder combined with common bile duct stones with a diameter of less than 1.2 cm. there are 3 treatment modes of LC+ERCP.
(1) LC followed by ERCP;
(2) ERCP during LC;
(The majority of patients are treated with ERCP followed by LC, which can minimize the occurrence of residual stones after surgery, and can also detect some specific biliary variants before surgery. For patients with severe infection, biliary decompression can also be performed through Endoscopic Nasobiliary Drainage (ENBD) to improve the general status of the patient before elective surgery.
ERCP during LC requires higher conditions in the operating room, which cannot be achieved in general hospitals, and post-operative ERCP after LC, mainly for cases of gallbladder combined with common bile duct stones less than 0.8 cm in diameter or residual stones after LCDE.
II. Comparison of near and long-term complications of the two treatment modes
Summarizing the relevant domestic literature, the complications after laparoscopy plus choledochoscopy mainly include: bile leakage, intra-biliary bleeding, pancreatitis, reflux gastritis, diarrhea, and abdominal pain. The most serious recent complication is biliary hemorrhage. Various complications after laparoscopy plus duodenoscopy include papillary hemorrhage, pancreatitis, reflux gastritis, diarrhea, and abdominal pain. The most serious recent complication was mainly pancreatitis, and the recent postoperative complications laparoscopy plus choledochoscopy were lower than laparoscopy plus duodenoscopy.
Three, two treatment modes of hospitalization time and cost comparison
To summarize the total cost and hospital stay of these two procedures in domestic tertiary care hospitals for comparison. Among them, the total hospitalization cost of LC+LCDE ranged from 15,000 to 20,000 yuan, and the average hospitalization days were 10 days, but it took about 40 days to remove the T-tube. the total hospitalization cost of LC+ERCP ranged from 25,000 to 30,000 yuan, and the average hospitalization days were 8 days.
IV. Summary
With the popularity of minimally invasive surgery, trans-laparoscopic cholecystectomy has become the gold standard for gallbladder surgery. Due to the improvement of minimally invasive surgical equipment and surgical techniques, more and more surgical procedures can be completed by minimally invasive methods. The traditional method of treating gallbladder combined with common bile duct stones is done through open abdomen, which results in longer hospitalization and recovery time for patients.
However, there are disadvantages of minimally invasive surgery, such as the need to keep a T-tube for more than 40 days after LC+LCDE, because the formation of sinus tracts around the T-tube is slow in lumpectomy, the early removal of the T-tube is easy to form bile leakage. The question of whether to leave a T-tube in the postoperative period is very controversial in traditional open surgery, and the same problem is faced in minimally invasive surgery, where the meaning of minimally invasive surgery is lost if the T-tube is left in place for too long.
The following conditions need to be met in order not to leave a T-tube in place after surgery.
(1) The diameter of the bile duct should be greater than 0.8 cm, otherwise it will cause biliary stricture after surgery;
(2) The lower end of the bile duct should be patent and free of residual stones;
(3) The lower end of the bile duct should be free of stenosis;
(4) The surgeon has skilled microscopic suturing technique. The laparoscopic bile duct stage I suture was carried out, which somehow solved the disadvantage of long-term indwelling T-tube. Continuous suture with absorbable thread is used, and the stitch distance is about 1.2 mm. If the stone is large or embedded in the common bile duct, the abdominal wall poke card can be removed and the stone can be removed directly by using a large S-type snake extraction forceps to reach into the bile duct from the abdominal wall defect left by the abdominal wall poke card. If the stone is large and hard, and the stone is embedded in the grade 2 bile duct, the stone can be lithotripsy by using liquid electrolysis machine.
The biggest advantage of LC+ERCP over LC+LCDE is that the patient does not need to have an indwelling T-tube and the hospital stay is short. If the patient’s condition is very critical and the coagulation mechanism is severely impaired, ENBD can be performed first without larger operations, which can play the role of biliary decompression and save the patient’s life, which is incomparable with other methods. The biggest disadvantage is that it requires two times of anesthesia clinically, the clinical cost is much higher than LC+LCDE, and the postoperative period is prone to hyperamylasemia.
Due to the incision of the sphincter of Oddi, patients are prone to retrograde infection after surgery and long-term results are not certain. The technique is also more demanding on the operator, with the papillary incision requiring a shallow rather than deep incision and a small rather than large incision. The duodenum is prone to perforation if diverticula are present. In case of large stones, repeated stone extraction may be required.
In conclusion, the treatment of gallbladder combined with common bile duct stones via LC+LCDE or LC+ERCP has its own advantages and disadvantages. For the patient, the method that allows for the shortest recovery time with relatively low cost and few complications is the best treatment.