Common bile duct stones (CBDS) is a common disease in hepatobiliary surgery and can be divided into primary and secondary types depending on the cause of the stones. As the incidence of gallbladder stones increases year by year, the incidence of secondary CBDS is also on the rise; in contrast, the incidence of primary CBDS is on the decrease.
In the past, the diagnosis of CBDS mainly relied on clinical symptoms, changes in liver function and abdominal ultrasonography. With the rapid upgrading of imaging equipment, a breakthrough in the diagnosis of CBDS has been achieved. Ultrasonography is convenient and practical, and can show the bile duct and gallbladder lesions inside and outside the liver; however, due to the influence of duodenum, it cannot clearly show the lower part of the common bile duct, and the false-negative rate of diagnosing CBDS is high. the accuracy rate of diagnosing CBDS by CT is higher than that of abdominal ultrasonography, but it is difficult to detect stones that do not appear on X-ray. Endoscopic retrograde cholangio pancreatography (ERCP) is the gold standard for the diagnosis of CBDS, but it is not recommended as a separate test because it is an invasive test. Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive cholangiopancreatic imaging technique, which can obtain imaging effects similar to direct cholangiopancreatography without contrast, and its diagnostic value is comparable to that of ERCP. Ultrasound endoscopy is a diagnostic technique that has emerged in recent years and can be used as a complementary test when MRCP is negative, but this technique is not yet popular.
The traditional treatment for CBDS is open cholecystectomy + biliary ductotomy + T-tube drainage, which is more traumatic and has more complications, slower recovery and longer hospitalization time. In recent decade, with the wide application of laparoscopy, cholangioscopy and duodenoscopy, the combined minimally invasive treatment plan of two-scope (laparoscopy + cholangioscopy) or three-scope (laparoscopy + cholangioscopy + duodenoscopy) has replaced the traditional open surgery to a considerable extent and become the first choice and main means of treatment for CBDS, which has led to a significant change in the treatment mode of CBDS. The treatment paradigm of CBDS has undergone a significant transformation. Modern treatment strategies for CBDS are reviewed as follows.
1. Minimally invasive treatment by bimicroscopic or trimicroscopic combination has become the mainstream of CBDS
The traditional treatment for CBDS is open cholecystectomy + choledochotomy + T-tube drainage, which has been widely used in the treatment of CBDS for many years because of its precise efficacy and high safety. However, there are obvious shortcomings in this procedure, namely, large surgical trauma, high residual stone rate, slow postoperative recovery, long hospitalization time, and high medical costs. There are many disadvantages of postoperative bile duct placement: (1) inconvenience, pain, and long postoperative hospital stay. (2) Loss of bile, abnormal water-electrolyte metabolism and digestive function, which affect the patient’s postoperative recovery. (3) Inadvertent activity during tube carrying, abdominal distension, coughing, and careless suture fixation may cause T-tube dislodgement; premature removal of T-tube, poor fistula formation, and rough operation may cause fistula tears, all of which may lead to serious complications of biliary fistula/biliary peritonitis. (4) Duodenal fistula. (5) Biliary tract infection and peri-T-tubular infection. (5) Stenosis and polyp formation around the opening of the T-tube irritated fistula.
With the rapid development and widespread use of laparoscopic, duodenoscopic, and cholangioscopic techniques, as well as changes in the CBDS paradigm,, two- or three-scope combined techniques have become the preferred treatment option for gallbladder stones combined with EBDS. There are theoretically four combination options of the three minimally invasive treatment techniques depending on the patient’s specific situation: (1) combined application of laparoscopic cholecystectomy (LC) and duodenoscopic papillary sphincterotomy for stone extraction (endoscopic sphincterotomy, EST); (2) combined (2) combined LC and laparoscopic common bile duct exploration (LCBDE); (3) combined LC and laparoscopic transcystic common bile duct exploration (LTCBDE) (3) combined LC and laparoscopic transcystic common bile duct exploration (LTCBDE): choledochoscopic exploration of the common bile duct through the cervical duct of the gallbladder and retrieval of the stone with a mesh basket under direct vision; (4) combined laparoscopic, choledochoscopic and duodenoscopic treatment options.
The above treatment options have their own advantages and shortcomings, and their selection should follow the treatment principle of “removing the lesion, relieving the obstruction, removing the stone, and clearing the drainage”. periampullary diverticaula (PAD) and the general condition of the patient, including whether there are serious complications, economic conditions, etc.
The following conditions should be considered as contraindications for minimally invasive treatment: (1) combined intrahepatic bile duct stones, requiring simultaneous resection of part of the liver or intrahepatic biliary tract exploration to retrieve stones; (2) biliary stenosis in the hilar region, requiring hilar choledochoplasty; (3) stenosis of the lower biliary tract, where malignancy cannot be excluded; (4) large, embedded or cast bile duct stones, which are difficult to retrieve through endoscopy; (5) combined severe cholangitis, (6) elderly patients with other organ disorders, who can hardly tolerate long time surgery.
However, due to the uneven economic development and regional differences in technology, the combined technology of fibroneoduodenoscopy, choledochoscopy and laparoscopy has not yet been popularized in primary hospitals, and traditional open surgery will remain the main or even the only treatment option for CBDS for a long time in the future.
2. Strategic choice of combined laparoscopy, cholangioscopy and duodenoscopy
As mentioned above, there are many minimally invasive treatment options for gallbladder stones combined with CBDS, each with its own characteristics and clinical indications, and reasonable selection of treatment modalities is essential to ensure the efficacy.
2.1 Combination of LC and EST
Although the combined use of LC and EST for the treatment of gallbladder stones combined with CBDS is a significant improvement over open surgery, there are also significant shortcomings: its implementation may induce serious complications such as biliary tract infection, acute pancreatitis, and perforation of the gastrointestinal tract. Depending on the chronological order of implementation of the two treatments, the combined application of LC and EST protocols include three types: EST before LC, LC before EST, and LC combined with intraoperative EST, each of which also has its own advantages and disadvantages.
The most commonly used approach is EST before LC, i.e., EST before LC to take CBDS, and data show that early LC within 3 days after EST is safe and feasible. The advantage of this treatment option is that even if EST fails, cholangiography can provide information about the bile cystic duct, intra- and extra-hepatic bile ducts and stones, which can be used as a reference for the subsequent choice of treatment (LBDE, LTCBDE or open biliary tract exploration). The disadvantage of this treatment option is that the treatment is done in two steps which increases the length of stay and medical costs.
The disadvantage of this treatment option is that if the EST fails, the patient will need to undergo another laparoscopic or open procedure. This procedure is mainly suitable for the following cases: acute cholecystitis with CBDS, emergency LC first, and then EST for CBDS after the condition has stabilized; small gallbladder stones and CBDS, with a greater possibility of EBDS draining into the intestine after LC, and elective EST for those who cannot drain on their own after LC.
The advantage of this procedure is that it can solve both gallbladder and CBDS in one treatment, which can reduce the hospitalization time and save the medical cost, and it also eliminates the pain of performing EST under non-general anesthesia; the disadvantage is that it requires high instrumentation, technical difficulty and complicated operation, which is difficult to carry out in general units.
2.2 Combined application of LC and LCBDE
The advantages of combined LC and LCBDE are: gallbladder stones and common bile duct stones can be completed at one time, shortening the hospital stay; the integrity of the Oddi sphincter is preserved, avoiding long-term complications caused by Oddi sphincter dissection. The disadvantage is that the integrity of the bile duct is destroyed by the common bile duct incision, which may cause the recurrence of bile duct stones or even bile duct stricture; there are also certain complications of leaving a T-tube in place. Although laparoscopic common bile duct exploration with one-stage suture technique can eliminate the pain of T-tube drainage, the indications (diameter of common bile duct >0.8 cm; lower bile duct is open; bile duct inflammation is not severe; bile duct stones are removed) and skilled microscopic suture technique should be strictly mastered, otherwise biliary stricture and bile leakage are likely to occur. In case of postoperative bile leak, nasobiliary drainage should be performed urgently, which can effectively treat bile leak and avoid peritonitis and secondary surgery. In order to avoid the occurrence of bile leak after one-stage biliary suture, surgeons have made many useful attempts, including the placement of biliary stents, pigtail drains or percutaneous transhepatic biliary puncture drainage before biliary suture, all of which are worthy of reference and should be used as appropriate according to the technical situation of our unit.
2.3 Combined application of LC and LTCBDE
The advantages of combined LC and LTCBDE are that the common bile duct is not incised and the integrity of the Oddi sphincter is not destroyed, and the cystic duct is closed by conventional methods after bile duct exploration, which is less invasive than LC alone.
The combined use of LC and LTCBDE is highly effective, even perfect, and should be the treatment of choice for gallbladder stones combined with CBDS if conditions permit. However, due to the influence of the diameter of the cystic duct, the location of the cystic duct converging into the bile duct and the angle of convergence, the spiral flap in the cystic duct and the location of the stone, as well as the difficulty of laparoscopic operation, the proportion of extrahepatic hepatic duct extraction via the cystic duct path is also much smaller than that of laparoscopic biliary tract exploration, T-tube drainage or one-stage suturing. In recent years, with the accumulation of experience in laparoscopic operation and the upgrading of choledochoscopy-related instruments, the success rate of transcystic duct is gradually improving.
2.4 Three-scope combined treatment plan
The three-scope combined treatment plan includes two modalities: duodenoscopy combined with laparoscopy, choledochoscopy and laparoscopy combined with intraoperative choledochoscopy and duodenoscopy.
Duodenoscopy combined with laparoscopy and choledochoscopy is adopted to place a nasobiliary drainage tube by duodenoscopy first and then perform LC combined with LCBDE after the biliary tract infection is controlled. This protocol is suitable for patients with biliary pancreatitis, severe cholangitis and Mirizzi’s syndrome. The advantages of this regimen are: the nasobiliary drainage tube can effectively drain bile, biliary infection can be controlled preoperatively, biliary leakage can be prevented postoperatively, and the nasobiliary tube can be removed directly 5-7 d after surgery without the need for reduodenoscopy.
The advantages of laparoscopic combined intraoperative choledochoscopy and duodenoscopy treatment plan are as follows: (1) After the combined application of LC and LCBDE, intraoperative duodenoscopic placement of nasobiliary drainage tube, one-stage biliary suture, treatment completed in one step, eliminating the pain and risk of staged treatment for patients. (2) Intraoperative choledochoscopy and duodenoscopy can cooperate with each other to solve complex CBDS that are difficult to be completed by choledochoscopy or duodenoscopy alone, such as: embedded stones in the lower bile duct and combined duodenal papillary stenosis. (3) Intraoperative choledochoscopy-guided operation of duodenoscopy can reduce the difficulty and complication rate of duodenoscopy: avoid pancreatitis caused by accidental entry of duodenoscope catheter into pancreatic duct and retrograde cholangiopancreatography; when papillary cannulation is difficult, biopsy forceps or lithotomy mesh is sent into duodenum through choledochoscope, zebra guidewire is pulled into bile duct, and then placed into nasobiliary duct with guidewire to avoid unnecessary EST; in combined In case of combined duodenal papillary stenosis requiring EST, there is guidance and support from the choledochoscopically placed guidewire or biopsy forceps, and the choledochoscope exposes the papilla externally, making EST more accurate even when there is papillary variation, thus reducing the risk of complications such as pancreatitis, bleeding, and perforation.
The combined triple-scope technique undoubtedly extends the indications for CBDS combined with gallbladder stones, but it requires mutual cooperation between surgeons and endoscopists, high instrument configuration requirements, technical difficulty, and complicated operation, and currently only hospitals of considerable size may perform it.
3.Treatment of simple CBDS
Both CBDS without gallbladder stones and postoperative CBDS after LC are primary CBDS, and EST lithotomy can be preferred.Ando et al. reported [24] that both CBDS without gallbladder stones and postoperative CBDS after LC were treated with EST, and the recurrence rate of CBDS in the postoperative CBDS group without gallbladder stones was significantly lower than that in the postoperative CBDS group after LC, which may be due to the intact function of the gallbladder The reason may be due to the intact function of the gallbladder, which can play the role of flushing the bile duct and preventing CBDS recurrence by draining bile. Therefore, cholecystectomy combined with intraoperative choledochoscopic lithotripsy is not recommended for the treatment of CBDS without combined gallbladder stones.
For recurrent CBDS with lower biliary strictures, laparoscopic choledo-intestinal anastomosis and laparoscopic choledochoduodenal anastomosis have been reported by domestic and foreign scholars, providing new ideas for minimally invasive treatment of extrahepatic bile duct stones, but this technique has not been widely performed. The reasons for this are, first of all, the high surgical risks, the high technical requirements of lumpectomy, and the high cost of surgical instruments. More importantly, laparoscopic choledoenteric anastomosis is only suitable for extrahepatic bile duct stones with lower bile duct stenosis, and the combination of intrahepatic bile duct stones, intrahepatic biliary stenosis, acute cholangitis, and acute pancreatitis is still a contraindication to laparoscopic choledoenteric anastomosis [25].
4, pay attention to the diagnosis and treatment of JPD combined with CBDS
JPD is closely related to the anatomy of the biliopancreatic confluence and often causes deformation of the duodenal papilla, compression of the biliopancreatic duct and narrowing of the opening, which are important causes of many biliopancreatic diseases. The literature reports that the incidence of JPD combined with biliary and pancreatic diseases is as high as 44.0% and 20.6%, respectively, the most common of which is CBDS [29,30]. At present, due to the lack of awareness of the relatively insidious and deep-seated etiology of CBDS, clinicians only see CBDS but not JPD or only treat CBDS but ignore JPD, resulting in repeated treatment of CBDS.
We retrospectively analyzed the clinical data of 164 patients with PAD combined with biliopancreatic system diseases admitted to our hospital between January 2006 and June 2011, and found that the number of confirmed cases of PAD in the first episode of biliopancreatic system diseases was 41, and 123 cases were missed, with a rate of 75%; the rate of missed patients in the second episode was 35% (43/123); the rate of missed patients in the third episode was 21% (43/123). The rate of underdiagnosis was 21% (9/43); the rate of underdiagnosis was 0% (0/9) in the fourth attack of the underdiagnosed patients. This shows that the problem of underdiagnosis and misdiagnosis of JPD combined with CBDS is more common and should be taken seriously by clinicians.
There is no unified standard for the treatment of JPD combined with CBDS, which mainly includes endoscopic and surgical treatment. Even if the stone is successfully removed, the primary disease cannot be eradicated, and the damage to the duodenal papillary sphincter results in the backflow of intestinal fluid into the bile duct, which destroys the biliary microenvironment and causes repeated secondary infections, leading to stone recurrence. The efficacy of surgical treatment for JPD is more certain, and specific procedures include diverticulectomy, diverticulotomy, and diverticulostomy. Diverticulectomy should be the most ideal method, but it is difficult to perform because of its close relationship with the bile duct and pancreas, and many complications; diverticulotomy is also often limited due to anatomical relationships; comparatively speaking, diverticulotomy is simpler and easier to perform, so it is most widely used, including biliary and gastrointestinal diversions, such as: choledojejunostomy Roux-en-Y anastomosis, Bi-II gastric and gastrojejunostomy, etc.
In conclusion, with the development of laparoscopic and endoscopic techniques, most CBDS can be treated by minimally invasive surgery. However, because the combined endoscopic and laparoscopic techniques are not yet popular in primary hospitals in China, it will take time to change the treatment strategy of CBDS.