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Laparoscopic transcystic common bile duct exploration versus transgastric endoscopic retrograde cholangiography during cholecystectomy after Roux-en-Y gastric bypass
Laparoscopic transcystic common bile duct exploration (LTCBDE) and transgastric endoscopic retrograde cholangiogram (ERC) are both safe procedures with low adverse event rates.
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Transgastric ERC was more often used in the acute setting and for larger stones.
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The LTCBDE procedure was on average half an hour faster.
Abstract
Background
Treatment of common bile duct (CBD) stones after Roux-en-Y gastric bypass (RYGB) poses a particular challenge given the altered anatomy and inability to perform a standard endoscopic retrograde cholangiogram (ERC). The optimal treatment strategy for intraoperatively encountered CBD stones in post-RYGB patients has not been established.
Objectives
To compare outcomes following laparoscopic transcystic common bile duct exploration (LTCBDE) and laparoscopy-assisted transgastric ERC for CBDs during cholecystectomy in RYGB-operated patients.
Setting
Swedish nationwide multi-registry study.
Methods
The Swedish Registry for Gallstone Surgery and ERCs, GallRiks (n = 215,670), and the Scandinavian Obesity Surgery Registry (SOReg) (n = 60,479) were cross-matched for cholecystectomies with intraoperatively encountered CBD stones in patients with previous RYGB surgery between 2011 and 2020.
Results
Registry cross-matching found 550 patients. Both LTCBDE (n = 132) and transgastric ERC (n = 145) were comparable in terms of low rates of intraoperative adverse events (1% versus 2%) and postoperative adverse events within 30 days (16% versus 18%). LTCBDE required significantly shorter operating time (P = .005) by on average 31 minutes, 95% confidence interval (CI) [10.3–52.6], and was more often used for smaller stones <4 mm in size (30% versus 17%, P = .010). However, transgastric ERC was more often used in acute surgery (78% versus 63%, P = .006) and for larger stones >8 mm in size (25% versus 8%, P < .001).
Conclusions
LTCBDE and transgastric ERC have similarly low complication rates for clearance of intraoperatively encountered CBD stones in RYGB-operated patients, but LTCBDE is faster while transgastric ERC is more often used in conjunction with larger bile duct stones.
Common bile duct (CBD) stones are encountered by routine intraoperative cholangiography in 7%–18% of elective laparoscopic cholecystectomies and even more frequently in the acute setting [
]. CBD stones are particularly challenging to treat after a Roux-en-Y gastric bypass (RYGB) because of the altered anatomy and the inability to perform a standard endoscopic retrograde cholangiography (ERC). Additionally, these patients have an increased risk of gallstone formation because of their obesity and rapid weight loss after the bariatric procedure [
Treatment options for CBD stone include preparation for two-stage management, laparoscopic or open choledochotomy, or single-stage intraoperative ERC and laparoscopic transcystic common bile duct exploration (LTCBDE). Other uncommon approaches include percutaneous transhepatic stone removal by employing interventional radiology. Surgeons in Sweden are trained in performing endoscopies with some also mastering ERCs. As intraoperative cholangiography is routine in Sweden, most hospitals have arrangements in place to perform either an intraoperative ERC or LTCBDE to handle any encountered CBD stones. Since many surgeons in Sweden already regularly perform intraoperative ERCs, the laparoscopy-assisted transgastric approach developed in 2002 for the Roux-en-Y anatomy is widely adopted [
Management of acute gallstone cholangitis after Roux-en-Y gastric bypass with laparoscopic transgastric endoscopic retrograde cholangiopancreatography.
Nearly all cholecystectomies and ERCs performed in Sweden are reported to the nationwide, population-based Swedish Registry for Gallstone Surgery and ERCs GallRiks [
The Swedish registry of gallstone surgery and endoscopic retrograde cholangiopancreatography (GallRiks): a nationwide registry for quality assurance of gallstone surgery.
]. Patients undergoing bariatric surgeries and reversal of their bariatric procedures are similarly reported to the validated Scandinavian Obesity Surgery Registry (SOReg) [
The optimal treatment strategy for intraoperatively encountered CBD stones in RYGB-operated patients has yet to be established. Studies have shown that single-stage intraoperative management is more cost-effective and efficient than two-stage management [
Impact of single-stage laparoscopic trans-cystic exploration on hospital procedures, admissions and length-of-stay in common bile duct stone clearance.
]. In this study, a registry-based comparison is made between, 2 single-stage procedures, LTCBDE and laparoscopy-assisted transgastric ERC for the management of CBD stones in RYGB-operated patients over a 10-year period.
Method
A nationwide multi-registry study was performed to include adult patients (>18 years old) with a history of RYGB, and having a cholecystectomy with an intraoperative finding of CBD stones. Patients were retrieved by cross-matching data from the national registries GallRiks (n = 215,670) and SOReg (n = 60,479). Data were extracted for cholecystectomies performed during 2011–2020. Exclusion criteria were any indication other than gallstone-related for the cholecystectomy, reversal of the Roux-en-Y anatomy before the cholecystectomy, and if the cholecystectomy was not the primary operation.
Laparoscopic transcystic CBD exploration
The indications for LTCBDE are fillings or equivocal defects at cholangiography, i.e., stones that are <10 mm and fewer than 10. Contraindications include stones ≥10 mm in size, stones located in the common hepatic duct, a fragile cystic duct, or ≥10 stones [
]. However, in the Roux-en-Y setting, the procedure may be attempted outside of these guidelines as a minimally invasive alternative to transgastric ERC. It may also be performed more liberally for smaller stones to ensure bile duct clearance at the end of the surgery.
LTCBDE is performed by the operating surgeon with the aid of an assistant at their normal positions on the patient’s left side. An additional long 5 mm trocar is placed under the right costal margin to achieve proximity to the cystic duct to facilitate the introduction of the choledochoscope (KARL STORZ SE & Co. KG:s, Tuttlingen, Germany). An introducer and a guidewire may be used to further facilitate the entry into the cystic duct. A winding cystic duct may require dilatation using a balloon catheter to allow for the passage of the endoscope. The choledochoscope is entered into the cystic duct while saline is flushed through the device with manual pressure to increase visibility and locate the papilla of Vater and any CBD stones. Smaller stones may be pushed or flushed out into the duodenum while larger stones are extracted using retrieval baskets (Gemini, Zero-tip, Boston Scientific, MA, USA). Stones that are wider than the cystic duct can either be crushed by the retrieval basket if fragile or fragmented using laser lithotripsy.
Laparoscopy-assisted transgastric ERC
The GallRiks database does not differentiate between different techniques of performing an intraoperative ERC, i.e., transgastric or using push-enteroscopy or similar techniques [
Comparison between enteroscopy-based and laparoscopy-assisted ERCP for accessing the biliary tree in patients with Roux-en-Y gastric bypass: systematic review and meta-analysis.
]. Based on practical knowledge of available surgical and endoscopic techniques in Sweden, a clinical assumption was made that the procedures were most likely performed using laparoscopy-assisted transgastric access [
The outcome of laparoscopy-assisted transgastric rendezvous ERCP during cholecystectomy after Roux-en-Y gastric bypass compared to normal controls [published correction appears in Obes Surg. 2022 Sep 28;:].
]. This is achieved by placing a trocar into the stomach remnant under laparoscopic visualization through which the endoscope can be inserted. A standard ERC or a rendezvous ERC can then be performed. The rendezvous technique involves using a guidewire placed through the cystic duct to facilitate entry into the CBD and reduce the risk of pancreatitis.
Statistical analysis
Data were stored and analyzed using SPSS version 28 (IBM Corporation, Armonk, NY, USA). Results were expressed as median with minimum and maximum values. Mann-Whitney U test was used for group comparisons of continuous values. Pearson's chi-squared test was used for the comparison of categorical variables, except for values fewer than 5, where Fisher’s exact test was used instead. All group comparisons were unpaired. A 2-sided P value of ≤.05 was considered statistically significant.
Ethical considerations
The study was approved by the Swedish Ethical Review Authority (2021-05,564-01) on November 10th, 2021. This retrospective study did not require informed consent.
Results
Demographics and overall handling of CBD stones
The data retrieved from the cross-matched registries found 550 patients with intraoperatively encountered CBD stones following RYGB. Nationwide 145 patients were managed with intraoperative transgastric ERC and 132 patients with LTCBDE. The procedures (n = 277) were reported from 47 hospitals (1–24 procedures/hospital), with 23 hospitals reporting fewer than 5 procedures. Study population demographics showed no statistical difference in body mass index, sex, or ASA (American Society of Anesthesiologists) scores between the 2 treatment modalities (Table 1). The remaining patients had their CBD stones flushed out with saline (n = 143), left without intervention (n = 38), had preparation for postoperative ERC (n = 14), or were treated by either laparoscopic choledochotomy (n = 18) or open choledochotomy (n = 58). Data on CBD stone management was missing for 2 patients (.4%).
Table 1Demographics and ASA score of the study population
Variables
Transcystic common bile duct exploration n = 132
Transgastric endoscopic retrograde cholangiography n = 145
Age (yr)
46 (19–69)
47 (19–74)
BMI (kg/m2)
28.9 (17.8–48.4)
30.8 (20.0–45.2)
missing
29 (22%)
43 (30%)
Sex
Female
110 (83%)
120 (83%)
Male
22 (17%)
25 (17%)
ASA score
I
38 (29%)
37 (26%)
II
76 (58%)
87 (60%)
III
18 (13%)
21 (14%)
BMI = Body mass index; ASA = American society of anesthesiologists.
Age and BMI are presented as median (min–max), while Sex and ASA scores are presented as count (percentage).
The studied procedures, LTCBDE and transgastric ERC were most often performed in the acute setting, where transgastric ERC was overrepresented (Table 2). Elevated bilirubin or icterus as a preoperative indication of cholestasis was significantly more common in the transgastric ERC group compared to the LTCBDE group (64% versus 45%, P = .002).
Table 2Outcome comparison between transcystic CBD exploration and transgastric ERC
Intraoperative and postoperative outcome comparisons
One intraoperative adverse event occurred in the LTCBDE group and 3 adverse events including 1 intestinal perforation occurred in the transgastric ERC group. The data did not specify whether the intestinal perforation was a consequence of the cholecystectomy or the ERC procedure. Postoperative adverse event rates were similar with more abscesses after ERC and more remaining CBD stones after LTCBDE, although lacking statistical significance (Table 2). The treated CBD stone sizes showed a difference between the techniques, with significantly larger stones being treated by transgastric ERC (P < .001) (Fig. 1). The total surgery time was significantly shorter for LTCBDE, being on average 31 minutes faster, 95% confidence interval (CI) [10.3–52.6] (P = .005, Fig. 2). LTCBDE also had a significantly shorter postoperative stay (P = .041), although the real difference was small with a median of 2 days for both procedures.
Fig. 1Bar chart showing the distribution of the largest stone sizes in millimeters by treatment method.
Laparoscopic choledochotomy was uncommon (18/550) with no center reporting more than 2 procedures. One intraoperative and 4 postoperative adverse events were reported. One patient was reported to have suffered both a postoperative biliary obstruction and a bile leak needing an ERC within 30 days. Open choledochotomy was complicated by 2 intestinal perforations and 14/58 (24%) suffered postoperative adverse events. Both open and laparoscopic choledochotomy resulted in longer postoperative stays of in median of 8 and 4 days respectively. The decision to leave CBD stones untreated was most frequent for the smallest stones of less than 4 mm in size (29/38) and resulted in a shorter surgery time of a median of 102 minutes. Among these patients, 4 postoperative adverse events were reported. One patient required an ERC within 30 days for bile leakage, another patient was reported with biliary obstruction, and 2 patients were treated for abscesses.
Discussion
In the present study, routine intraoperative cholangiograms were performed during cholecystectomies which may not be the case in other countries. Interestingly, 45% of patients with CBD stones did not have a preoperative suspicion, suggesting that an intraoperative cholangiogram is probably advisable for post-RYGB cholecystectomies. LTCBDE and transgastric ERC were the most common treatment options together with those simply flushed out with saline. While laparoscopic choledochotomy may be safe in experienced hands, it is uncommon in Sweden with no hospital reporting more than 2 procedures. Open choledochotomy caused the highest morbidity with higher adverse event rates and the longest postoperative stay.
The comparison between LTCBDE to transgastric ERC found that overall, both procedures showed comparable results with few complications. The main difference was related to the size of extracted CBD stones. LTCBDE was used to a higher extent in patients with small stones. Possible explanations may be the relative ease by which the procedure is performed, increasing its use even for smaller stones <4 mm, or the fact that fewer had preoperative cholestasis suggesting a relatively easier clearance of the observed stones. Since transgastric ERC is more invasive, surgeons may hesitate to perform the procedure when anticipating that smaller stones can pass spontaneously. The stones left for spontaneous passage in this study did not show an increased risk for adverse events, however, the numbers are too few to draw any definitive conclusions and follow-up beyond 30 days was not available. Previous studies have shown that the spontaneous passage of ductal stones without symptoms or complications cannot be predicted by the number or size of stones, or by the diameter of the bile duct [
Natural course vs interventions to clear common bile duct stones: data from the Swedish registry for gallstone surgery and endoscopic retrograde cholangiopancreatography (GallRiks).
]. It is not possible to anticipate which patients will experience complications related to residual stones, such as biliary colic, jaundice, or pancreatitis, which may be severe or potentially fatal [
]. An attempt to reach stone clearance intraoperatively can therefore be advocated in the post-RYGB patient, particularly since the LTCBDE technique allows for a minimally invasive approach to ascertain bile duct clearance.
Intraoperative transgastric ERC required a laparoscopy-assisted transgastric access route to enable an otherwise standard ERC technique [
Management of acute gallstone cholangitis after Roux-en-Y gastric bypass with laparoscopic transgastric endoscopic retrograde cholangiopancreatography.
Comparison between enteroscopy-based and laparoscopy-assisted ERCP for accessing the biliary tree in patients with Roux-en-Y gastric bypass: systematic review and meta-analysis.
The outcome of laparoscopy-assisted transgastric rendezvous ERCP during cholecystectomy after Roux-en-Y gastric bypass compared to normal controls [published correction appears in Obes Surg. 2022 Sep 28;:].
]. This approach may be preferable if a setup for a single-stage ERC procedure is already in place. Of note, LTCBDE requires the training of a new technique that is minimally invasive, resource-effective, non-specific to the Roux-en-Y anatomy and has a modest learning curve enabling surgeons to perform a single-stage procedure on their patients [
Impact of single-stage laparoscopic trans-cystic exploration on hospital procedures, admissions and length-of-stay in common bile duct stone clearance.
Analysis of the total cohort also showed significantly shorter surgery time for patients treated with LTCBDE. Some confounding factors could be that intraoperative ERCs were used more frequently in the acute setting, that more patients had cholecystitis, or that the larger stones, more often treated with ERC, took longer to clear.
The usage of validated national registries with excellent coverage over a 10-year period was a major strength of the current study [
]. The study population was therefore significant and allowed for intervention comparisons in groups for CBD stone extraction in RYGB patients. Since both LTCBDE and transgastric ERC have been used in Sweden for several years, the study design using GallRiks enabled comparison of the procedures in a relatively large cohort, given the rare condition. A limitation of the study is that the registry only reliably reports adverse events that occur intraoperatively or postoperatively within 30 days and the comparison can therefore miss later events. Furthermore, adverse events are not specified as being caused by the cholecystectomy or the intervention for the CBD stones. In addition, registration was done postoperatively, and a failed or aborted procedure may not have been reported, as only the final procedure was registered. Furthermore, the study showed that larger stones were more often handled by ERC. If more than 1 procedure was available, the stone size may cause a bias by influencing the surgeon’s choice of intervention. However, it is unlikely that many hospitals and surgeons had access to more than 1 of these 2 procedures.
Conclusion
This study shows that both LTCBDE and transgastric ERC procedures can be used for the single-stage extraction of CBD stones during cholecystectomies in RYGB patients with good outcomes and low adverse event rates. LTCBDE is faster and was more often used for smaller CBD stones, while transgastric ERC is more often used in conjunction with larger bile duct stones.
Disclosures
The authors have no commercial associations that might be a conflict of interest in relation to this article.
References
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Maguire D.
Ireland A.
Fitzgerald E.
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A prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of choledocholithiasis revisited.
The Swedish Registry of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks):– Årsrapport 2016, p.30. 2017 (Available from:)
Management of acute gallstone cholangitis after Roux-en-Y gastric bypass with laparoscopic transgastric endoscopic retrograde cholangiopancreatography.
The Swedish registry of gallstone surgery and endoscopic retrograde cholangiopancreatography (GallRiks): a nationwide registry for quality assurance of gallstone surgery.
Impact of single-stage laparoscopic trans-cystic exploration on hospital procedures, admissions and length-of-stay in common bile duct stone clearance.
Comparison between enteroscopy-based and laparoscopy-assisted ERCP for accessing the biliary tree in patients with Roux-en-Y gastric bypass: systematic review and meta-analysis.
The outcome of laparoscopy-assisted transgastric rendezvous ERCP during cholecystectomy after Roux-en-Y gastric bypass compared to normal controls [published correction appears in Obes Surg. 2022 Sep 28;:].
Natural course vs interventions to clear common bile duct stones: data from the Swedish registry for gallstone surgery and endoscopic retrograde cholangiopancreatography (GallRiks).
Funding: The study was supported by research grants from Swedish Government Grant for Clinical Research (ALF), Region Skåne Regional Research Grants (Doktorand-2021-0935), and Einar and Inga Nilsson’s foundation.
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