P-BN50 Transcystic CBD Exploration: The First-Line Treatment of CBD Stone - A Single Centre 12-month Review of Practice

Background In the UK around 15% of the population will have gallstones and as such biliary pathology makes up a significant proportion of emergency and elective general surgical practice. Within this 10% will have choledocholithiasis; the management of which remains widely varied. A single-stage laparoscopic cholecystectomy with transcystic common bile duct exploration has been shown to be a safe and efficient option avoiding a choledochotomy and risks associated with ERCP. The aim of this study was a 12-month review of data following the adoption of this approach; assuming that laparoscopic transcystic CBD exploration was the ideal treatment for CBD stones. Methods This was a retrospective, single-centre, observational study. All patients who underwent a laparoscopic transcystic CBD exploration from June 2020 to June 2021 were included both in the elective and emergency setting. Patient demographics were varied with ages ranging from 15 to 76 and ASA classification of 1 -3, showing a significant proportion with comorbidities. Data collection was done through a review of a contemporaneous operative database and a follow-up morbidity period of 30 days was cross-referenced with electronic healthcare records. The primary outcome studied was CBD stone clearance. With secondary outcomes measures including complications, length of stay and the role of preoperative imaging versus intraoperative cholangiogram. Results A total of 49 patients were included within the study, of which 61% were emergency. The primary outcome of CBD stone clearance was achieved in all elective patients with one emergency patient requiring ERCP for a retained fragment at day 8. There were no other complications in the remaining 48 patients, making the 30-day morbidity 2% upon review of electronic care records. One patient was converted to open due to concern with regards to potential CBD injury but this was demonstrated not to be the case. The median duration of hospital admission was 3 days with a range from 0- 15, with the median stay for elective cases being 1 day. Finally, 39 patients underwent intraoperative cholangiograms prior to duct exploration as a means of identifying CBD calculi and delineating anatomy. Those 10 that did not; all had an MRCP within 30 days of surgery demonstrating CBD calculi and as such proceeded straight to CBD exploration. Conclusions Laparoscopic cholecystectomy and transcystic CBD exploration, with adequate training and exposure, is a viable and safe first-line approach for all cases of choledocholithiasis both in the elective and emergency setting; demonstrating advantages by avoiding additional procedures thereby reducing costs, inpatient bed days and a risk of further complications and being truly minimally invasive. The principal findings of this study were that the transcystic CBD exploration route can achieve successful CBD stone clearance rates in close to 98 per cent of patients with a low morbidity rate, and a short median length of hospital stay. This study of course has several potential limitations; given it was a retrospective single-centre observational study there is likely a degree of selection bias and although follow up was complete in all patients to 30 days via electronic care record it was not routine practice to offer face to face follow up given the low incidence of delayed complications. On the basis of this review, the transcystic approach has become the primary strategy for patients with common bile duct stones within this unit.

EP.TH.754One Year Experience of Laparoscopic Common Bile Duct Exploration in a District General Hospital Using Ambu Disposable Scope

Aim Common bile duct (CBD) stones are the most common cause of obstructive jaundice. Laparoscopic exploration of the CBD with laparoscopic cholecystectomy has been preferred to endoscopic treatment, as a single-stage modality of treatment for CBD stones. This procedure was started in a District General Hospital in May 2019 using the standard port sites and Ambu® aScope™ 2 single-use flexible scope. Methods Retrospective analysis of outcome of all laparoscopic CBD explorations done in a District General Hospital between May 2019 and September 2020. Results A total of ten laparoscopic CBD explorations were carried out during the identified period, the main indications were young patients (40%), referral by gastroenterologist (40%) and failed endoscopic retrograde cholangiopancreatography (ERCP) (20%). The mean age (±SD) was 54.7 (± 19.2) and 70% of patients were females. Two thirds of the operations were done in emergency setting, with choledochotomy approach being used in 60% of cases and primary closure in all cases. The average length of stay (±SD) after the operation was 3.1 (±1.9). Only one patient developed a haemoserous collection that required a laparoscopic washout, none of the patients required readmission. Conclusion Laparoscopic CBD exploration can be performed safely in a district general hospital, the disposable Ambu® aScope™ 2 is safe, feasible and cost-effective substitute to the reusable choledochoscope. Provision of this laparoscopic CBD exploration at district general hospital level is more convenient to patients and can reduce referrals to regional hepatobiliary units, and therefore provide a good training opportunity for surgical registrars in this setting.

EP.FRI.530 ‘Emergency’ Laparoscopic Common Bile Duct (CBD) Exploration: Is this the right time to change?

Aims Common Bile Duct (CBD) stones are becoming more common on surgical emergency take and accounts for up to 20 % of patients presenting with acute biliary pathologies. The hospital stay is prolonged whilst waiting for Endoscopic Retrograde Cholangio Pancreatography (ERCP). We aim to evaluate the feasibility, safety and cost-effectiveness of emergency laparoscopic CBD exploration (LCBDE) in these patients. Methods A cohort of patients with CBD stones underwent emergency LCBDE between January 2016 and December 2020 at a regional hospital in the United Kingdom was retrospectively reviewed. Results In total, 11 LCBDE were performed on emergency list. All patients were admitted with acute symptoms of either obstructive jaundice cholangitis or pancreatitis. All procedures were performed with choledochotomy. The mean patient age was 58 years and male-to-female ratio was 2:9. 3 patients (27%) had T- tube otherwise all ducts were primarily closed. Average hospital stay was 8.5 days. 1 patient returned to theatre for retained stone of 11mm. There was no 30 days mortality. There were no readmissions. Initial analysis with small number of patients showed, performing these procedures on emergency basis not only improved patient’s overall experience but also benefitted NHS Trust by approximately £18,500 as per the National Tariff System 2020/21. Conclusions Emergency LCBDE is safe, feasible and cost effective. We can safely aim to increase the proportion of LCBDE performed as an emergency case, where clinically appropriate, to reduce the financial burden and improve patient’s outcome with overwhelming NHS Trust funds.

Retained plastic biliary stent presenting with obstructive jaundice: a case report

Forgotten stents may lead to serious complications. We present a case report of a forgotten common bile duct (CBD) fully covered plastic stent presenting with Obstructive Jaundice. A 66 years-old female patient presented with features of obstructive jaundice. Further enquiry revealed a history of ERCP guided biliary stent placement 12 years ago, after which she was lost to follow up. An endoscopic attempt to retrieve the old stent and relieve biliary obstruction was unsuccessful, and a fresh stent was placed across the CBD following a sphincterotomy. CT showed evidence of a stent in situ, alongside calcified fragments of the previous stent and multiple CBD stones. Patient was taken up for surgery and Roux-en-y hepaticojejunostomy was performed following CBD exploration and retrieval of the stent-stone complex.

Fractured T Tube Fragment in Common Bile Duct during Retrieval: An Unforeseen Mishap

Common bile duct (CBD) exploration by surgical method—open or laparoscopic, traditionally involved using a T tube to take care of postoperative intraluminal pressure and edema. The complications of T tube include bile leak after removal, formation of biliary fistula, excoriation of the skin, dehydration, saline depletion, retained T tube fragment, CBD obstruction, cholangitis, pancreatitis, and duodenal erosion. Here, we report a case of retained T tube fragment after an attempted removal in an operated case of choledocholithiasis, which was managed by endoscopic retrograde cholangiopancreatography and balloon catheter removal of the remnant.

Laparoscopic CBD Exploration (LCBDE) a better and safe option for large CBD stones

Background: Conventionally, common bile duct stones (CBDS) are removed with help of ERCP. However, if CBDS are larger than 10 mm, then the ERCP failure rate to retrieve CBDS becomes high. In that case, open or laparoscopic common bile duct exploration (LCBDE) is other alternative. In this era of minimally invasive surgery, laparoscopic CBD exploration (LCBDE) seems to be a better option than open approach, but in our set up the safety of LCBDE is questioned. Aim: To see the conversion rate as well as complications associated with LCBDE. Material & Methods: Methods: This is a retrospective analysis of data of patients who underwent Laparoscopic Common Bile Duct Exploration (LCBDE) for large CBD stones at Fatima Memorial Hospital Lahore. Results: Since 2012, 29 patients of large (≥10 mm) CBD stones were included in this study. Among them 20(69.9%) were females and 9(31.01%) were males. The mean CBD stone size was 13 mm. Stones were extracted transcystically in 4 case and Transcholedochal stone extraction was done in 25 cases. The average duration of surgery was 130 minutes, but all cases were completed successfully without converting to open approach. There was minor bile leak in 3 patients which was managed successfully without any further intervention. No other complication was observed with LCBDE and even no retained stone was reported. Conclusion: Laparoscopic CBD exploration is safe and effective method of dealing CBD stones especially of large size when the chances of ERCP failure to retrieve stones are high. Keywords: Laparoscopy, ERCP, common bile duct,

Laparoscopic common bile duct exploration with primary closure over an ante-grade biliary stent-our experience

Background: Aim of study was the assessment of laparoscopic common bile duct (CBD) exploration with primary closure over an ante-gradely placed endo-biliary stent for CBD stones in terms of operating time, rate of conversion to open procedure, hospital stay, postoperative complications and residual disease.Methods: Our data was analysed retrospectively over a period of 5 years (2015-2020) on all the patients who underwent laparoscopic CBD exploration with primary closure over an ante-gradely placed endo-biliary stent followed by cholecystectomy at SMHS hospital, Srinagar, J and K, India. Total of 30 such patients were identified.Results: The mean procedure time was 93.5±23.16 minutes. There were no intra operative complications encountered in the study. Four patients were converted to open (13.33%). The mean duration of hospital stay was 4.56±1.99 Days. The total number of patients that developed post-operative complications was 7 (23.33%). The most frequently encountered post-operative complication was stent migration (13.33%). The next most common post-operative complication was minor biliary leak (10%) which resolved spontaneously. There was no mortality experienced during the study. Two patients (6.66%) had residual stones and 28 (93.33%) patients had complete clearance of the CBD.Conclusions: Laparoscopic CBD exploration with primary closure over an ante-gradely placed endo-biliary stent is a feasible option and is a safe procedure. Endoscopic removal of the stent can safely be done after an interval of 6-8 weeks.