Open Cholecystectomy with Choledocholithotomy with Choledochoduodonostomy

Choledochoduodonostomy was first reported by Riedel in July, 1888. The first successful choledochoduodonostomy was performed by Oskar Sprengel in Germany in 1891 [1].  Sanders in 1946, reporting on 22 cases, agreed that choledochoduodonostomy was physiological in principle, and gave a wide margin of safety and convalescence. Plenk and Hartl of Lenz in 1949 reported 95 cases of choledochoduodonostomy in which there was one post-operative death. He also described 293 hospital cases and emphasized that purulent cholangitis is cured if the stoma was large enough, as the most important thing was drainage. Becker Bernhard in 1950 insisted that cholangitis is rapidly cured when the bile can escape freely [2]. 

Mallet-Guy and Descotes in 1955 reporting on 100 cases of cholecystectomy with choledochoduodenostomy done between1938-53, found excellent and good results in 95 patients, partial improvement in 1 case, and recurrences due to stricture occurring in 4 cases. Hosford reported 19 cases in 1957 and Iszak and Steiger in1958, in analyzing 66 cases, noted that choledochoduodenostomy gave fewer complications than sphincterotomy. Schwartz, Benshimol and Hurwitz in 1959 used choledochoduodonostomy and found it satisfactory in treating 5 cases of stenosis of the lower part of the common bile duct [3]. 

David P. Vogt et al [3] in year 1981 did a study over 147 patients from year 1962-1979, where they performed cholecystectomy with choledocholithotomy with choledochoduodonostomy in CBD stones. They found that it was effective in retained, recurrent and impacted stones. H Okamoto and K Miura in 2017 retrospectively analysed the surgical results of 130 patients treated by CDD after cholecystectomy between 1991 and 2013. They demonstrated that CDD was simple, effective and adequate therapy for the treatment of patients with common bile duct stones, especially in cases where endoscopic treatment was difficult, failed or stones were recurrent. Long-term complications of this procedure, such as reflux cholangitis, stone recurrence, pancreatitis, and sump syndrome were relatively uncommon and acceptable.

Laparoscopic Cholecystectomy with Laparoscopic CBD Exploration

First laparoscopic cholecystectomy was performed by Prof. Dr. Erich Muhe of Germany in year 1985. He published the result of his 97 cases of laparoscopic cholecystectomy at the congress of the German Surgical Society in 1986. From then it has become the gold standard for treating GSD. Bernhard Riedel removed several choledochal stones and carried out a side-to-side anastomosis between the bile duct and duodenum in year 1888. This was the first choledochoduodenostomy (CD) [4].  Because over 80% of gallbladders are removed laparoscopically, simultaneous laparoscopic common bile duct exploration is another option to treat CBD stones. It is a difficult procedure that requires a great deal of laparoscopic skill therefore it is done in fewer patients. The advantages are clear; the gallbladder and CBD stones are taken care of simultaneously in a minimally invasive manner that leads to shorter hospital stay and less pain than the corresponding open procedure or laparoscopic cholecystectomy/ERCP combination.

Stones extraction may be performed by a trancystic or choledochotomy approach. Several techniques have been described for primary common bile duct closure (PCBDC) following choledochotomy. Closure over a T-tube is a technique with up to 15% complications, comparable figures to open surgery. A viable alternative to reduce complications from T-tube is the laparoscopic placement of an antegrade stent, followed by bile duct closure. However this technique also presents a high rate of complications according to several series, including the development of acute postoperative pancreatitis (AP). Recently, primary bile duct closure during surgery following intraoperative cholangiography (IOC) has been proposed as a safe, reproducible technique with fewer complications than the previous procedures, where internal or external common bile duct drainage was performed. 

Jacobs et al [5] in 1991 were among the first ones to describe the technique of laparoscopic choledochotomy after laparoscopic cholecystectomy. In a smaller series consisting of 8 patients, they were able to clear the duct in seven patients and in one patient under radiological control. They routinely placed the T-tube through which a cholangiogram was performed 7-10 days later.

Berci and Morgenstern in 1994 published one of the largest prospective study of laparoscopic common bile duct exploration consisting of 226 patients. After laparoscopic cholecystectomy operative cholangiogram, which was performed routinely, revealed a very high incidence of unsuspected common bile duct stones. The majority of patients underwent transcystic common bile duct exploration (83%) compared with laparoscopic choledochotomy (17%). Conversion to the open approach was necessary in 19% of transductal approach cases. The total incidence of the perioperative complication rate was 5.7% with one operative death. Complications within 30 days of the procedure occurred in 7% and included pancreatitis, bile leakage, cholangitis, bleeding, ductal injury, wound infection and jaundice. Retained stones were discovered in 2.6% of cases [6].

Williams et al [7] in 1994 has compared laparoscopic CBDE with primary closure (37patients) versus T- tube (26patients) drainage of the CBD and found no significant difference in the duration of operation, incidence of wound infection, surgical or other complications following operation between the two groups. However, the postoperative stay was significantly prolonged in the T- group. 

Chung-Ngai Tang et al [8] analyzed prospective data of laparoscopic exploration of common bile duct during 1995-1999. During this period 27 LCBDE were performed in patients with concomitant gall stones and common bile duct stones, in which half of the laparoscopic exploration of CBD were performed after unsuccessful endoscopic retrieval (13 patients). Laparoscopic exploration of common bile duct was also indicated in patients younger than 16 years (14 patients) because there was a concern about the potential long term complications of papillotomy - like papillary stenosis and ascending cholangitis. 

Croce et al [9] in 1996 analysed 33 patients for laparoscopic cholecystectomy with choledochotomy with primary closure of common bile duct. None had signs of postoperative CBD stricture. They concluded that laparoscopic cholecystectomy with choledochotomy with primary closure is a very good operation with a high success rate and low morbidity. No mortality was reported. Results of the study suggested that intraductal biliary drainage (T-tube) is useless and its specific complications are well known. 

Dag Arvidsson et al [10] in 1998 did retrospective study in 39 patients who underwent laparoscopic common bile duct exploration after cholecystectomy either by a transcystic technique or by choledochotomy, between September, 1992 and April, 1995. Stone removal was achieved in 32/39 patients (82%) by laparoscopic approach. Reasons for failure were attributed to inexperience and the result of technical difficulties or stones that were too large for transcystic approach or with impacted stones in common bile duct. Post operative morbidity was low with no mortality. 

Martin et al [11] in 1998 conducted 300 laparoscopic common bile duct exploration procedures (transcystic approach or with choledochotomy) along with cholecystectomy. Choledochotomy was associated with a higher morbidity rate, particularly with T-tube insertion. According to authors most patients with gallbladder and common bile duct stones should expect a curative one-stage laparoscopic procedure without the need for external biliary drainage or ERCP.

Memon et al [12] in 2000 stated that laparoscopic common bile duct exploration along with laparoscopic cholecystectomy is feasible, safe and effective procedure that carries a low morbidity and mortality. They recommended that the use of real time on table cholangiography should be used in a selected group of patients (history of jaundice, pancreatitis and so forth) in order to correctly identify those harbouring common bile duct stones. The conversion to open exploration of common bile duct should be considered in case of failure to progress with the laparoscopic common bile duct exploration beyond 2 hours, large stone load in a grossly dilated common bile duct, difficult anatomy or unsuspected pathology such as Mirrizzi’s syndrome of the biliary tract and uncontrollable bleeding. 

Zhang et al [13] in 2004 studied 55 patients (27 patients of primary closure and 28 patients of T- tube drainage). In comparison primary duct closure group had less the total quantity of postoperative transfusion and hospital costs, shorter postoperative hospital stay. The incidence of severe complications that needed reoperations was 10.7%, and all of them were caused by T-tubes. There was no mortality. They concluded that primary duct closure in laparoscopic choledochotomy can avoid the deficiency of T-tube drainage, and it is feasible and safe and lower complications in treating the common bile duct stones.

In a study by Petelin LC with LCBDE was found successful in clearing CBD stones in 97.2% of patients. They concluded that selective laparoscopic placement of T- tubes in patients requiring choledochotomy appears to be a safe and effective to routine T-tube drainage of the ductal system and LCBDE may be employed successfully in the vast majority of patients harbouring CBD stones [14]. 

Ha et al [15] in 2004 stated that the insertion of a T-tube is not without complication and the patients have to carry it for several weeks before removal. According to their results primary closure of the common bile duct is feasible and as safe as T-tube insertion after laparoscopic cholecystectomy with laparoscopic choledochotomy for stone disease. Prospective studies of laparoscopic management of CBD stones that included more than 200 patients reported success rates ranging from 88% to 97% (mean 92%). The morbidity rates after laparoscopic CBD exploration ranged from 7% - 19% (mean 8%). However, some trials demonstrated shorter hospital stay as the only benefit of laparoscopic procedures. 

Zhi-Tao Dong et al [16] performed a study between year2002-12. Patients with CBD stones were studied prospectively from 2002-2012 in a single center. A total of 194 patients were randomly assigned to group A (LC with LCBDE with primary closure) with 101 cases and group B (LC with LCBDE with T-tube drainage) with 93 cases. There was no mortality. The incidence of overall postoperative complications was insignificantly lower in group A. Laparoscopic primary closure of CBD is safe and effective for the management of CBD stones, and can be performed routinely as an alternative to T-tube drainage. 

Eryk Naumowicz did a study between 2004 and 2011 three groups of 100 patients were treated for obstructive jaundice caused by choledocholithiasis. The first group of 42 patients underwent ERCP followed by laparoscopic cholecystectomy. The second group of 23 patients underwent open cholecystectomy and common bile duct exploration, whereas the third group of 35 patients underwent laparoscopic cholecystectomy with laparoscopic common bile duct exploration. One stage laparoscopic cholecystectomy with common bile duct exploration is the least invasive, safer and more effective procedure [17]. 

Israel Abella ́n Morcillo et al [18] did a study between January 1999 and July 2012. 206 patients with common bile duct stones underwent Laparoscopic common bile duct exploration along with laparoscopic cholecystectomy. The closure of the common bile duct over a T-tube (36 patients) and closure over an antegrade stent (133 patients) is done, but due to a high incidence of acute pancreatitis in the last 16 patients, primary closure is performed. Primary closure of the common bile duct after Laparoscopic common bile duct exploration (LCBDE) seems to be superior to closure over a T tube and stents. The learning curve seems to have a positive impact on the outcomes, making it a safe and reproducible technique especially for patients aged under75 years.

T.E. Platt et al [19] did study for comparing LC with LCBDE among old age group in year January 2015-January 2017 for the management of choledocholithiasis. Study performed among 124 patients. Patients were divided into 2 groups based on age (Group A:<65 years vs Group B:>65 years) for comparative analysis. Group A includes 65 whereas Group B includes 59 patients. Despite higher frequency of comorbidities, LC with LCBDE in elderly patients is safe and effective, and has similar outcomes to younger patients. Therefore elderly patients with choledocholithiasis should be offered LCBDE as an alternative to ERCP. 

Surgical fraternity has not yet arrived at any consensus for adequate treatment of gall stones with choledocholithiasis. ERCP came and quickly established itself as a preferred method of treatment for common bile duct stones. Sequential treatment in the form of pre- operative endoscopic retrograde cholangio-pancreatography followed by laparoscopic cholecystectomy is considered as optimal treatment till date. 

With refinements in technique and expertise in field of minimal access surgery, many centres in the world have started offering one stage management of choledocholithiasis by LC with LCBDE. Various modalities have been tried for entering into concurrent common bile duct (CBD) [transcystic (TC) vs transcholedochal (TD)], for confirming stone clearance (intraoperative cholangiogram vs chholedochoscopy), and for closure of choledochotomy (T-tube vs biliary stent vs primary closure) during LCBDE. TD stone extraction is involved with an increased risk of bile leaks and requires more expertise in intra-corporeal suturing and choledochoscopy.

Because over 80% of cholecystectomies are done laparoscopically, simultaneous laparoscopic common bile duct exploration can be done. The advantage is that the gallbladder and CBD stones are taken care of simultaneously in a minimally invasive manner. Successful laparoscopic management of CBD stones depends on several factors including surgical expertise, adequate equipment, the biliary anatomy and the number and size of CBD stones.LC with LCBDE is another good treatment option for patients with GSD and CBDS, when adequate expertise is available.

1. Okamoto, H. et al. “Current assessment of choledochoduodenostomy: 130 consecutive series.” The Annals of the Royal College of Surgeons of England, vol. 99, no. 7, September 2017, pp. 545–549.

2. Capper, W.M. “External choledochoduodenostomy: an evaluation of 125 cases.” The British Journal of Surgery, vol. 49, no. 215, November 1961, pp. 292–300.

3. Vogt, D.P. and R.E. Hermann. “Choledochoduodenostomy, choledochojejunostomy or sphincteroplasty for biliary and pancreatic disease.” Annals of Surgery, vol. 193, no. 2, February 1981, pp. 161–168.

4. Baron, T.H. et al. ERCP. 3rd ed., Elsevier, 2018.

5. Jacobs, M. et al. “Laparoscopic choledocholithotomy.” Journal of Laparoendoscopic Surgery, vol. 1, no. 2, 1991, pp. 79–82.

6. Berci, G. and L. Morgenstern. “Laparoscopic management of common bile duct stones.” Surgical Endoscopy, vol. 8, no. 10, October 1994, pp. 1168–1175.

7. Williams, J.A. et al. “Primary duct closure versus T-tube drainage following exploration of the common bile duct.” Australian and New Zealand Journal of Surgery, vol. 64, no. 12, December 1994, pp. 823–826.

8. Tang, C.N. et al. “Laparoscopic exploration of common bile duct: a solution to difficult choledocholithiasis.” Annals of the College of Surgeons of Hong Kong, vol. 5, no. 3, September 2001, pp. 104–109.

9. Croce, E. et al. “Laparoscopic choledochotomy with primary closure.” Surgical Endoscopy, vol. 10, no. 11, November 1996, pp. 1064–1068.

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11. Martin, I.J. et al. “Towards T-tube free laparoscopic bile duct exploration: A methodologic evolution during 300 consecutive procedures.” Annals of Surgery, vol. 228, no. 1, July 1998, pp. 29–34.

12. Memon, M.A. et al. “Laparoscopic common bile duct exploration: The past, the present, and the future.” The American Journal of Surgery, vol. 179, no. 4, April 2000, pp. 309–315.

13. Zhang, L.D. et al. “Primary duct closure versus T-tube drainage following laparoscopic choledochotomy.” Zhonghua Wai Ke Za Zhi, vol. 42, no. 9, May 2004, pp. 520–523.

14. Petelin, J.B. “Laparoscopic common bile duct exploration.” Surgical Endoscopy, vol. 17, no. 11, November 2003, pp. 1705–1715.

15. Ha, J.P. et al. “Primary closure versus T-tube drainage after laparoscopic choledochotomy for common bile duct stones.” Hepato-Gastroenterology, vol. 51, no. 60, November 2004, pp. 1605–1608.

16. Dong, Z.T. et al. “Primary closure after laparoscopic common bile duct exploration versus T-tube.” Journal of Surgical Research, vol. 189, no. 2, June 2014, pp. 249–254.

17. Naumowicz, E. et al. “Results of treatment of patients with gallstone disease and ductal calculi by single-stage laparoscopic cholecystectomy and bile duct exploration.” Videosurgery and Other Miniinvasive Techniques, vol. 9, no. 2, June 2014, pp. 179–189.

18. Morcillo, I.A. et al. “Laparoscopic common bile duct exploration: Lessons learned after 200 cases.” Cirugía Española, vol. 92, no. 5, May 2014, pp. 341–347.

19. Platt, T.E. et al. “Laparoscopic common bile duct exploration: A preferential pathway for elderly patients.” Annals of Medicine and Surgery, vol. 30, June 2018, pp. 13–17.