A survey of European-African surgeons' management of common bile duct stones

Abstract

Background

Common bile duct (CBD) stones can be managed by either endoscopic retrograde cholangiopancreatography (ERCP) or laparoscopic common bile duct exploration (LCBDE). The aim of this survey was to document the management of CBD stones by European-African HPB Association (E-AHPBA) members.

Methods

All 331 members of the E-AHPBA were invited by personal email to participate to an online survey.

Results

Ninety-three (28%) surgeons replied within 2 months. Responding surgeons were attending surgeons (84%), working as HPB surgeons (75%) in academic hospitals (73%). In patients with clinically suspected CBD stones, MRCP was the preferred diagnostic test for 61% of respondents. LCBDE was the preferred therapeutic strategy for 11 (12%) respondents only. Previous gastric surgery was an absolute contraindication to ERCP for 47% of respondents. Absence of CBD dilation was considered an absolute contraindication for LCBDE in 24% of respondents. Yearly caseload exceeded 10 patients for only 30% of 56 centers performing LCBDE. The transcystic approach was preferred by 39% of surgeons performing LCBDE. There was considerable variation amongst respondents with regard to type and duration of drainage, bile duct closure technique and follow-up after LCBDE.

Conclusion

Indications for single-stage LCBDE are not standardized and do not appear well established across E-AHPBA members.

Background

Common bile duct stones are found in 10–18% of patients undergoing cholecystectomy for gallstones.¹ CBD stones can be managed either by endoscopic retrograde cholangiopancreatography (ERCP) or by laparoscopic common bile duct exploration (LCBDE) with transcystic or transductal stone extraction. There are no significant differences in the mortality, morbidity, number of retained stones, and failure rates between the single-stage LCBDE and two-stage endoscopic management with ERCP before or after cholecystectomy.¹ However, single-stage LCBDE may shorten duration of total hospital stay and reduce hospital costs.² In addition, LCBDE presents as an attractive approach in those patients with CBD stones where access to the ampulla is problematic even after previous cholecystectomy. Despite its well described efficacy, the uptake of LCBDE seems to have remained limited to a small number of specialized centers throughout the world.

The aim of this study was to document the management of common bile duct stones by HPB-specialized surgeons across Europe and Africa by surveying European-African Hepato- Pancreato- Biliary Association (E-AHPBA) members.

Methods

An online survey was developed using the SurveyMonkey^® software available at www.surveymonkey.com. All 331 members of the E-AHPBA were invited to participate by personal e-mail on the 12th of January 2015. Two e-mail reminders were sent on the 18th and the 23rd of January 2015, respectively. The online survey was closed on March 12th of 2015. The study was officially endorsed by the E-AHPBA. The questionnaire on the management of common bile duct stones consisted of four main topics to assess current practices: (i) diagnostic work-up and preferred management of common bile duct stones, (ii) use of intraoperative cholangiography, (iii) technical aspects on LCBDE, and (iv) follow-up after management of common bile duct stones by either ERCP or LCBDE. Although the names of the surgeons and the centers were mentioned in the questionnaire, data were reported anonymously. Results are expressed as percentages or absolute numbers.

Results

In total, ninety-three E-AHPBA members (28%) completed the survey within 2 months. LCBDE was performed in 56 (60%) of respondents' centers. The respondents' demographics are shown in Table 1.

Table 1.

Respondents' demographics

	n [%]
Type of hospital
Academic	68 [73]
Non-academic teaching	22 [24]
Non-teaching	3 [3]
Training level
Resident	11 [12]
Fellow	4 [4]
Attending	78 [84]
Age
Younger than 30	1 [1]
30–39	18 [19]
40–49	37 [40]
50–59	28 [30]
60 or older	9 [10]
Years of professional experience
0–5	19 [20]
5–10	23 [25]
10–20	20 [22]
>20	31 [33]
Specialty
General Surgery	20 [22]
HPB Surgery	70 [75]
Other	3 [3]
Complex laparoscopic GI surgery
Yes	64 [69]
No	29 [31]
Personal experience with LCBDE
Never	5 [9]
<10 cases/year	34 [61]
10–25 cases/year	14 [25]
>25 cases/year	3 [5]

The preferred diagnostic work-up and management of common bile duct stones by respondents (n [%]) are shown in Table 2. In patients with confirmed CBD stones, LCBDE was the preferred therapeutic strategy for 11 respondents (12%) only. Of these, two respondents were between 30 and 39 years old, 3 between 40 and 49 years old, 5 between 50 and 59 years old and one respondent was older than 60. Three (3%) respondents preferred intraoperative ERCP.

Table 2.

Diagnostic work-up and management of CBD stones

	n [%]
Preferred diagnostic test for clinically suspected CBD stones
Abdominal ultrasound	13 [15]
MRCP	54 [61]
Endoscopic ultrasound	8 [9]
Intraoperative cholangiography	8 [9]
ERCP	5 [6]
Preferred strategy for confirmed CBD stones
ERCP prior to cholecystectomy	71 [81]
ERCP after cholecystectomy	1 [1]
LCBDE	11 [12]
Other	5 [6]
ERCP available 24/7
Yes	59 [67]
No	26 [30]
Variable	3 [3]
Influence of ERCP availability on management of CBD stones
Yes	16 [18]
No	42 [48]
Selectively	30 [34]
Referral for cholecystectomy after ERCP + sphincterotomy
Never	1 [3]
Selectively	2 [6]
Within 2 weeks after ERCP + sphincterotomy	16 [52]
Between 2 and 6 weeks	8 [26]
More than 6 weeks	4 [13]

The relative and absolute contraindications of ERCP and LCBDE are compared in Table 3. In addition, the estimated risk of papillary or CBD stenosis after papillotomy and choledochotomy, respectively is also shown in Table 3.

Table 3.

Relative and absolute contraindications of ERCP and LCBDE

	ERCP + ES	LCBDE
	n [%]	n [%]
Absolute contraindications
Oral anticoagulants	32 [39]	19 [22]
Antiaggregant agents	18 [20]	12 [14]
Duodenal diverticulum	0 [0]	NA
Acute cholecystitis	1 [1]	1 [1]
Acute pancreatitis	11 [13]	13 [15]
Acute cholangitis	1 [1]	7 [8]
Previous gastric surgery	41 [47]	NA
No absolute contraindication	17 [19]	NA
Previous cholecystectomy	NA	3 [3]
No CBD dilation	NA	21 [24]
Other	6 [7]	6 [7]
No absolute contraindication	NA	41 [47]
Relative contraindications
Oral anticoagulants	32 [36]	33 [38]
Antiaggregant agents	41 [47]	31 [35]
Duodenal diverticulum	29 [33]
Acute cholecystitis	6 [7]	12 [14]
Acute pancreatitis	16 [18]	21 [24]
Acute cholangitis	2 [2]	15 [17]
Previous gastric surgery	42 [48]	NA
Previous cholecystectomy	NA	17 [19]
No CBD dilation	NA	37 [42]
Other	2 [2]	9 [10]
Estimated risk of stenosisa
<1%	31 [35]	24 [27]
1–5%	41 [47]	40 [45]
5–10%	16 [18]	19 [22]
10–20%	0 [0]	4 [5]
>20%	0 [0]	1 [1]

ES, endoscopic sphincterotomy; NA, not applicable.

^aStricture formation only applicable for LCBDE with choledochotomy.

The respondents' approach to intraoperative cholangiography is shown in Table 4.

Table 4.

Intraoperative cholangiography

	n [%]
Experience with laparoscopic cholecystectomy
Yes	84 [98]
No	2 [2]
Intraoperative cholangiography practice
Never	15 [17]
Routine	10 [12]
Selective	61 [71]
Intraoperative cholangiography after ERCP for CBD stones
Always	14 [16]
Only when no normalization of liver function tests	4 [5]
Only when in doubt of stone clearance	57 [66]
Never	6 [7]
Other	5 [6]

Technical aspects of the LCBDE procedure and details of postoperative management and follow-up after LCBDE are shown in Table 5, Table 6, respectively.

Table 5.

Operative technique of LCBDE

	n [%]
Preferred approach for LCBDE
Transcystic	22 [39]
Choledochotomy	18 [32]
No preference	14 [25]
Not applicable	2 [4]
Choledochotomy closure
Interrupted non-absorbable monofilament sutures	2 [4]
Continuous non-absorbable monofilament sutures	1 [2]
Interrupted absorbable monofilament sutures	21 [38]
Continuous absorbable monofilament sutures	10 [18]
Interrupted absorbable braided sutures	7 [13]
T-drain	11 [20]
Not applicable	4 [7]
Drainage after LCBDE
Always	30 [54]
Not after transcystic approach	23 [41]
Never	3 [5]
Type of drain
Closed system with active suction	15 [27]
Closed system with passive drainage	26 [46]
Open system	9 [16]
Not applicable	6 [11]

Table 6.

Postoperative care after LCBDE

	n [%]
Time before drain removal after LCBDE with choledochotomy
24 h (POD1)	10 [18]
48 h (POD2)	26 [46]
>48 h	9 [16]
Not applicable	7 [13]
Other	4 [7]
Continued IV antibiotic prophylaxis after LCBDE
Never	3 [5]
Routinely	21 [38]
In case of acute cholangitis	31 [55]
Other	1 [2]
Postoperative biochemistry with liver function tests
No	2 [4]
POD1	29 [52]
POD2	8 [14]
On demand	15 [27]
Other	2[4]
Long-term follow-up (>1 year) after LCBDE
No	15 [27]
Selectively	29 [52]
Always	12 [21]
Type of follow-up examination after LCBDE
None	4 [7]
Clinical examination	3 [5]
Clinical examination + biochemistry (liver function tests)	31 [55]
Clinical examination + biochemistry (liver function tests) + radiological imaging	16 [29]
Other	2 [4]
Preferred radiological assessment tool for suspected CBD stricture after LCBDE
Computed tomography	1 [2]
Abdominal ultrasound	3 [5]
MRCP	48 [87]
Endoscopic ultrasound	2 [4]
Other	1 [2]

Discussion

The data from this survey confirm the low use of LCBDE as a valuable therapeutic alternative for the management of common bile duct stones. Indeed, only a very small group of respondents reported performing LCBDE. Of those performing LCBDE only 30% had an annual case-load exceeding 10 patients.

In patients with confirmed CBD stones, only 12% of respondents routinely performed single-stage LCBDE while 81% of the respondents preferred ERCP first. This tendency towards endoscopy is also seen in American surgeons, of whom 75% are estimated to prefer preoperative ERCP.³ The single-stage and two-stage approach have been shown to have comparable outcomes in terms of bile duct clearance, morbidity and mortality.¹ LCBDE is associated with a shorter hospital stay, lesser cost, no manipulation of the sphincter of Oddi resulting in less bacterial colonization, less risk of cholangitis, less risk of malignant transformation and pancreatitis.⁴ In a prospective randomized trial, Ding et al. found a significantly higher recurrence rate of CBD stones after the two-stage procedure at longer-term follow-up.⁵ Some of the main drawbacks from LCBDE are the requirement of advanced laparoscopic technical skills and the cost of acquiring a fragile (video) choledochoscope. In addition, lack of operating time to plan this semi-urgent procedure and pressure on operating programs are further potential drawbacks that may explain why LCBDE has not been well adopted by surgeons. Nevertheless, ERCP can often also be technically challenging or virtually impossible in the growing population of patients who have undergone bariatric surgery such as gastric bypass with Roux-en-Y reconstruction. In these patients LCBDE presents an efficient approach to manage common bile duct stones, even after previous cholecystectomy.

Furthermore, CBD stones have been shown to be present on intraoperative cholangiography at the time of laparoscopic cholecystectomy in up to 13% of patients who had preoperative ERCP, due to interval passage of stones or to false-negative completion cholangiogram after ERCP.⁷ This may be explained by the time interval between ERCP and laparoscopic cholecystectomy or by an incomplete clearance of the CBD after ERCP.

Up-front intraoperative cholangiography and LCBDE during cholecystectomy reduces the risk of recurrent common bile duct stones or retained stones after ERCP.

Almost half of respondents denied being influenced by the availability of ERCP when deciding about the therapeutic approach. This finding may be interpreted in two different ways: either they do not have the option of performing a single-stage LCBDE or they prefer LCBDE under any circumstance.

Recent literature does not support routine intraoperative cholangiography,¹ yet only 12% of respondents mentioned performing cholangiography routinely. Most respondents (71%) only selectively performed intraoperative cholangiography. In a prospective study, Collins et al. found a 25% false-positive rate of CBD stones at intraoperative cholangiography and persistent CBD stones likely to cause morbidity postoperatively in 2.5% of patients only.⁸ Puhalla et al. stated that intraoperative cholangiography is a fundamental prerequisite of LCBDE, recommending routine intraoperative cholangiography allowing the surgeon to verify bile duct anatomy and thereby guiding the surgical approach to bile duct exploration (i.e. transcystic or via choledochotomy), and preventing bile duct injury. It also allows the evaluation of the size of the CBD and stone location.⁹

The transcystic approach was preferred over choledochotomy by most respondents. This transcystic approach can be performed in approximately 50% of patients. It is limited to the extraction of relatively small stones and does not allow exploration of the hepatic duct. Choledochotomy is indicated in patients with large impacted stones, a dilated CBD or an unfavorable anatomy of the cystic duct.⁶ Choledochotomy closure requires advanced laparoscopic suturing skills and does not appear to be well standardized. Despite high complication rates of T-tubes in literature, 20% of respondents still preferred this technique over primary closure of choledochotomy. Khaled et al. provided evidence that primary closure of the CBD is a safe and efficient alternative for T-tube placement.10, 11 Current literature only supports placement of T-tubes in case of pronounced CBD inflammation.¹ In a single-center retrospective study by Hua et al., additional indications for T-tube placement were inflammatory stricture of the sphincter of Oddi and unremovable small mural stones.¹¹

Post-operative bile leak rate after choledochotomy occurs in 1.6–7% of patients and is significantly associated with successful duct clearance and with the diameter of the CBD, with a 18-fold increased risk when the CBD diameter is less than 8 mm.¹¹

Post-operative management after LCBDE varied a lot among different respondents. As many as 52% recommended selective long-term follow-up after LCBDE. The current data did not provide information about the indications for selective follow-up. Selective follow-up, only after choledochotomy (not after transcystic extraction) would be a reasonable option. Indeed, primary closure of choledochotomy may be at increased risk of bile duct stricture. However, this was not confirmed in a recent retrospective study.¹² Surprisingly, virtually no prospective data exist on the incidence of stricture formation after choledochotomy in the laparoscopic era.

With a response rate of 28% the envisaged 30% rate which is acceptable for surveys was almost met. The relatively poor response rate may be explained by a limited interest of hepatobiliary surgeons in LCBDE. An explanation for this discrepancy may be that in most countries gallstone pathology is managed by general surgeons rather than by specialized hepatobiliary surgeons. As only members of the E-AHPBA were invited to participate in this survey, a bias may have been introduced. Indeed, the authors believe that the number of surgeons actually performing LCBDE is probably even overestimated in this survey due to ‘self-selection bias’ or the so-called ‘volunteer effect’. Since the survey was only sent to members of the E-AHPBA, a surgical association, an additional bias may have been introduced as only the surgical point of view was reported in this study. Nevertheless, the current outcomes confirm the results of a Japanese survey that was also addressed to interventional endoscopists.¹³

Tutton et al. showed that equivalent outcomes in CBD clearance and complication rates are achievable by higher surgical trainees and staff members provided that they received appropriate training.¹⁴ Therefore, the authors support the implementation of intraoperative cholangiography and LCBDE in the curriculum of general and HPB surgery trainees. Simulator-based curriculums for LCBDE have been developed for residents and could help to improve their performance.¹⁵ LCBDE should be included both in the general surgery and HPB curriculum in order to earn an equal foot besides ERCP for the management of CBD stones. Especially in centers with great case-load of gastric surgery, including laparoscopic Roux-en-Y gastric bypass, expertise in LCBDE may be necessary. In the authors' own experience, multidisciplinary management is a key step to introduction of LCBDE as a preferred approach for patients with CBD stones. The development of a clinical pathway may further reduce both diagnostic and therapeutic delays in the management of CBD stones.

Conclusions

Indications for single-stage LCBDE are not standardized and the procedure is infrequently performed by E-AHPBA members. As ERCP is often contraindicated after previous gastric surgery and the number of patients undergoing Roux-en-Y gastric bypass continues to rise, inclusion of LCBDE in the curriculum of both general and HPB surgery training should be promoted. Initiatives from E-AHPBA may increase the uptake of this technique by its members.

Conflicts of interest

None declared.

Appendix A. Supplementary data

The following is the supplementary data related to this article: