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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 15  |  Issue : 2  |  Page : 117-121

Common bile duct exploration with transpapillary stenting versus T-tube drainage for management of irretrievable common bile duct stones


1 Department of General Surgery, Faculty of Medicine, Al Azhar University, Assiut, Egypt
2 Department of Tropical Medicine, Faculty of Medicine, Al Azhar University, Assiut, Egypt

Date of Submission07-Mar-2017
Date of Acceptance12-Sep-2017
Date of Web Publication21-Nov-2017

Correspondence Address:
Muhammad Abd El-Gawad Shawky
Department of Tropical Medicine, Faculty of Medicine, Al Azhar University, Assiut, 71524
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_16_17

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  Abstract 

Background Common bile duct (CBD) stones are present in 10–18% of patients undergoing cholecystectomy for chronic calcular cholecystitis. Treatment of CBD stones is still controversial. However, CBD stones can be treated by cholecystectomy plus CBD exploration or by precholecystectomy or postcholecystectomy endoscopic retrograde cholangiopancreatography (ERCP) in two stages. If CBD exploration is performed and biliary decompression is needed after stone removal, the placement of transpapillary stent (TS) shows promising results in avoiding T-tube–related complications.
Aim We aimed to evaluate the efficacy and complications of two approaches used for the management of CBD stones: intraoperative transpapillary CBD stent and T-tube external biliary drainage.
Patients and methods Between May 2015 and May 2016, 24 patients underwent CBD exploration for treatment of irretrievable CBD stones. Included patients were randomly subjected to either CBD TS or T-tube drainage for management of irretrievable CBD stones after failure of ERCP.
Results CBD exploration and TS placement (15 patients) was achieved either by a choledochotomy or through the cystic duct. There was no mortality in our series. Patients with a T-tube external biliary drainage (nine patients) had more surgery-related complications and a longer hospital stay. Postoperative ERCP to remove the CBD stent was successful in all cases.
Conclusion Surgical transpapillary CBD stenting seems to be an effective method for management of irretrievable CBD stone with less surgical-related complications and less hospital stay and should be the first option in management of such patients.

Keywords: biliary drainage, choledocholithiasis, common bile duct stones, irretrievable, laparoscopy, T-tube


How to cite this article:
Hassan AM, Mohammed AQ, Shawky MA. Common bile duct exploration with transpapillary stenting versus T-tube drainage for management of irretrievable common bile duct stones. Al-Azhar Assiut Med J 2017;15:117-21

How to cite this URL:
Hassan AM, Mohammed AQ, Shawky MA. Common bile duct exploration with transpapillary stenting versus T-tube drainage for management of irretrievable common bile duct stones. Al-Azhar Assiut Med J [serial online] 2017 [cited 2018 Feb 19];15:117-21. Available from: http://www.azmj.eg.net/text.asp?2017/15/2/117/218847




  Introduction Top


Gallstones occur in ∼15% of the general population [1]. In patients who undergo cholecystectomy for gall bladder stones, ∼10–18% also have common bile duct (CBD) stones [2],[3]. In people without jaundice, with normal duct size on transabdominal ultrasound (US), the prevalence of CBD stones at the time of cholecystectomy is less than 5% [2],[4]. The natural history of CBD stones is not known, although postcholecystectomy complications appear to be more frequent and severe in patients with CBD stones than in those without CBD stones [5]. Up to a third of people with stones identified at intraoperative cholangiogram clear their ducts spontaneously after surgery [4].

CBD stones are often complicated by obstructive jaundice with cholangitis or pancreatitis. Patients with asymptomatic bile duct stones are at a risk of developing obstructive jaundice and cholangitis and require intervention [6]. CBD exploration and removal of the stones relieve the obstruction, and the patient can then be subjected to laparoscopic or open cholecystectomy at the same session, or as two different procedures.

There are several approaches to the treatment of CBD stones, including surgical treatment alone [either open CBD exploration with external biliary drainage or the laparoscopic common bile duct exploration (LCBDE)] or a combination of endoscopy and surgical treatment [preoperative or postoperative endoscopic retrograde cholangiopancreatography (ERCP) to clear the CBD stones].

Endoscopic intervention removes stones from the duct with no further need for surgical exploration of the bile duct. When the stones are cleared by ERCP, the patient can then proceed to either laparoscopic or open cholecystectomy. ERCP (either preoperatively or postoperatively) is the preferred method at most centers for managing patients with suspected CBD stones. However, ERCP may be complicated by hemorrhage, pancreatitis, cholangitis, and duodenal perforation in 5–11%, and may lead to mortality in up to 1% [7]. ERCP failure rates of 5–10% are reported [8]. Also, at the time of ERCP, some patients do not have stones [9], so patients may risk these complications. Absence of duct stones during ERCP can vary from 15 to 25% [4]. Magnetic resonance cholangiopancreatography use in patients with suspected duct stones is preferred for the diagnosis of CBD stones before endoscopic or surgical intervention [10].

Laparoscopic exploration and removal of CBD stones has become technically feasible, and some studies have shown that laparoscopic treatment of CBD stones is as effective as ERCP [11]. Transcystic or transcholedochal exploration of the CBD can be performed at the same time of laparoscopic cholecystectomy (LC) [11],[12]. Clayton et al. [11] demonstrated that ERCP and LCBDE are similar procedures regarding stone clearance, morbidity, and mortality. Advantages of surgical CBD exploration are keeping the sphincter anatomy not distorted and cholecystectomy can be performed during the same procedure. However, surgical CBD exploration can be associated with bile leak [9] and CBD stricture as long-term complications [8].

The ERCP has many advantages over open surgery, which made it the preferred method of treating patients with duct stones. However, 10–15% of CBD stones cannot be removed with ERCP [13],[14].

The possibility of managing CBD stones during the same session of LC has given it advantages over other surgical approaches. However, laparoscopic exploration of the bile ducts requires advanced surgical skills and proper equipment. The removal of biliary stones can be achieved either through the cystic duct or by choledochotomy. The transcholedochal route is associated with a higher morbidity rate, mainly owing to the frequent use of a T-tube for decompression of the biliary system. So, the use of a transpapillary stent (TS) appears to be more valuable and safe method with satisfactory outcomes [15].

The current study is performed to compare the efficacy and outcome of the two surgical approaches − TS and T-tube drainage − used for the management of irretrievable CBD stones after failure of ERCP.


  Patients and methods Top


Between May 2015 and May 2016, 24 patients who underwent CBD exploration to treat irretrievable CBD stones at Al Azhar University Hospitals were retrospectively analyzed.

All of these patients were adults (above 18 years) with CBD stones diagnosed by one or more of the imaging modalities: abdominal US, abdominal computed axial tomography, and magnetic resonance cholangiopancreatography. In all of these patients, ERCP failed to manage CBD stones owing to variable reasons: impacted stone, big size, or retained stone. All patients were admitted to Al Azhar University Hospital, General Surgery Department, Assiut.

All of these patients were treated by a CBD exploration, and stone extraction was attempted either transcystically or transcholedochal. The results in patients with TS placement (15 patients) were compared with those who had an external biliary drainage (nine patients).

Types of surgical interventions

Open technique

Open surgical bile duct clearance is achieved by open surgical exploration of the CBD, which is achieved by either transcystic or choledochotomy techniques include flushing (with or without the pharmacological aid of glucagon or buscopan), balloon extraction, and mechanical lithotripsy or Dormia basket extraction.

Laparoscopic technique

LC was done with the patient in the prone position using the American technique. Four trocars were used: one 5 mm in the epigastrium, one 10 mm in the umbilicus, two 5 mm in the right flank. Intraoperative cholaniography (IOC) was done for all patients through a catheter inserted into the cystic duct to confirm the presence of CBD stones, then LCBDE was done under fluoroscopy using a Web-2×4 basket through a choledochotomy or through the cystic duct. The choledochotony approach was preferred when there are multiple stones, low junction of cystic duct with the CBD, or intrahepatic stones.

To decompress the biliary system, either a TS or T-tube external drainage was done according to the availability of accessories, surgical experience, and presence of residual stones. For TS, a 7-Fr plastic stent was used. In the choledochotomy approach, primary closure using interrupted 5–0 polydioxanone was done, and a T-tube was inserted. An IOC was done to ensure patency, exclude leakage, and to confirm appropriate positioning of the T-tube. Then, LC was done.

Outcomes

  1. Mortality at maximal follow-up.
  2. Morbidity: complications from surgical procedures, such as bile duct injuries, pancreatitis, cholangitis, postoperative hemorrhage, postoperative complications requiring intervention, and pulmonary, cardiac or renal complications.
  3. Retained stones: inability to clear the ductal stones with the planned technique by the end of that procedure.
  4. Failure to complete the planned procedure: Inability to perform the planned procedure owing to technical reasons such as failed cannulation or difficult Calot’s dissection, or because of impacted stone.
  5. Conversion of surgery from TS to external biliary drainage.


Follow-up

Postoperatively, patients stayed in the hospital with daily clinical and laboratory evaluation. After discharge, the patients were followed up regularly every 3 months during the first postoperative year and then annually.

Statistical analysis

Statistical analysis was done using IBM-SPSS (IBM Corp, Armonk, New York, USA) 22 for Windsows 10 operating system. Categorical data parameters were expressed as frequency and percentage whereas quantitative data were expressed as mean±SD. Independent t-test was used for comparison of quantitative data between the two groups and χ2-test for categorical data comparison. P was assumed significant if it was less than 0.05.


  Results Top


Our study aimed at comparing CBD exploration plus transpapillary stenting with T-tube external biliary drainage for treatment of irretrievable CBD stones after failure of ERCP. CBD stenting was done through transcystic or choledoctomy in patients with or without previous cholecystectomy.

Of the 24 patients who were enrolled in our study, all underwent a CBD exploration with successful clearance of stones. A total of nine (37%) patients underwent a transcystic stone extraction, and 15 (63%) patients required a choledochotomy. TS was done in 15 (63%) patients and T-tube was placed in nine (37%) patients.

Data were compared between both groups (TS and T-tube groups). There were no statistically significant differences in demogarphic characteristics and preoperative factors ([Table 1]).
Table 1 Demographic data and preoperative factors among the two groups

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Overall, morbidity in the T-tube group was 38% (five patients), with three patients developed acute pancreatitis, one developed cholangitis, and one with an accidental displacement of the T-tube. Regarding the transpapilary group, one patient presented with a biliary peritonitis in the immediate postoperative period that required reoperation. There were no intraoperative or postoperative deaths ([Table 2]).
Table 2 Postoperative complications

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Regarding operative times, TS required shorter surgical time than T-tube insertion, which were statistically significant (P=0.000). Moreover, the transpapillary group recovered faster than the T-tube group, hence required shorter hospital stays than the T-tube group. This difference was also statistically significant (P=0.005). ERCP was done for all patients in the transpapillary group for stent removal 25–45 days after surgery, with no ERCP related complications or failure. In addition, five (33.3%) patients in this group presented with residual CBD stones which were successfully extracted during the same ERCP session. In the T-tube drainage group, cholangiography was performed 25–45 days after surgery, to ensure patency before removal of the drain ([Table 3]).
Table 3 Time of surgery, hospital stay, and removal of stent or drainage

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  Discussion Top


In the early era of LC, a two-stage approach – LC with precholecystecomy or postcholecystecomy ERCP – was the preferred surgical approach for management of CBD stones [16]. This two-stage approach has many disadvantages including the possibility of missing diagnosis of CBD stones by the routine liver function tests and abdominal US done preoperatively [17]. On the opposite side, ERCP is associated with 7–15% morbidity [18],[19], and 5–20% cannulation failure [17].

A single-stage surgical approach in treatment of CBD stones has many advantages with success rate equivalent to ERCP [19]. Additionally, the increasing utilization of IOC has increased the diagnosis of CBD stones and thus preventing the possibilities of surgeons to deal with unsuspected biliary stone. However, LCBDE and stone extraction is safe and effective method for managing CBD stones in the hands of skilled surgeon – either transcystically or through a choledochotomy [17]. Owing to the less complications [20], LCBDE through the cystic duct remains the access of choice [21]. However, a low cystic duct-CBD junction and large CBD diameter (≥10 mm) and the presence of multiple or intrahepatic stones are all indications of a choledochotomy owing to difficulty to extract stones through the cystic duct in these situations.

In 10 (41.6%) patients in our study, the CBD exploration was performed through the cystic duct, and 14 (59.3%) patients through a choledochotomy. A T-tube was inserted for biliary decompression in nine of the 14 patients who had a choledochotomy.

T-tube was a safe and effective method for biliary decompression and prevention of postcholecystectomy biliary leakage in cases of retained CBD stones after choledochotomy in the prelaparoscopic era [22]. However, T-tube-related morbidity is 15–28% irrespective of the used approach − open or laparoscopic approach [23],[24]. The most encountered complications are postoperative cholangitis, biliary leakage after removal of the tube, and accidental T-tube displacement [24]. It is believed that laparoscopic endobiliary stents avoid the postoperative T-tube–related complications with more patient compliance, less hospital stay, and rapid recovery [25].Our study revealed that the transpapillary group has many advantages over the T-tube group: less morbidity, less hospital stays, and less time of surgery, which were supported by the findings of Perez et al. [22].

The main disadvantage of the TS is the need for postoperative ERCP to remove the stent. However, postoperative ERCP has the advantage of removing retained and newly formed CBD stones. In our study, ERCP was successfully performed for all patients with no cannulation failure or ERCP-related complications. So, the presence of residual stones and the absence of ERCP cannulation failure should be considered in deciding the CBD exploration and biliary decompression approach [26].

However, our study has some weakness of having a retrospective approach and being performed in a single institution. So, we recommend further randomized controlled trials to support our findings.


  Conclusion Top


The surgical CBD exploration with TS has several advantages over T-tube external biliary drainage. It has lower morbidity rates, shorter hospital stays, shorter surgical time, and additionally the advantage of postoperative CBD clearance from any residual or newly formed CBD stones by the postoperative ERCP, so avoiding the need for repeated surgical or endoscopic intervention.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Clayton ES, Connor S, Alexakis N, Leandros E. Meta-analysis of endoscopy and surgery versus surgery alone for common bile duct stones with the gallbladder in situ. Br J Surg 2006; 93:1185–1191.  Back to cited text no. 11
    
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