Introduction

Single-stage procedure for the treatment of cholecysto-choledocolithiasis is associated with a success rate > 95%, shorter length of hospital stage and lower costs compared with the two-stage procedure of surgery after endoscopic retrograde endoscopic cholangiopancreatography (ERCP)^1,2.

Difficult common bile duct clearance is the main cause of failed endoscopic or laparoscopic procedures due to stones impacted in the mid or distal common bile duct with proximal dilatation and narrowing of the biliary duct distal to the stone^3-6. We refer to this presentation as acute total common bile duct obstruction syndrome (ATCBDO).

The aim of this study is to describe the results obtained with the management of these patients.

Material and methods

The cohort was made up of consecutive patients with difficult common bile duct stones treated between 2018 and 2020. Difficult common bile duct stones are defined as those that cannot be removed by usual laparoscopic or endoscopic procedures (baskets, balloon dilation, etc.).

Inclusion criteria: patients with stones impacted in the mid or distal common bile duct with proximal dilata tion and narrowing of the biliary duct distal to the stone diagnosed during intraoperative cholangiography (IOC) in patients without cholangitis or by in ERCP in those with cholangitis.

Exclusion criteria: patients with history of cholecystec tomy and ASA grade 4.

Variables analyzed: age, sex, total bilirubin levels (be fore surgery and before ERCP), operative time, interval between ERCP and surgery, conversion rate, need for choledocotomy, reoperations, postoperative morbidity and mortality.

Surgical technique: once common bile duct stones have been identified by IOC, transcystic instrumenta tion with Dormia basket are used to remove the stones. If this technique fails, a wire is introduced distal to the stone and the Dormia basket is introduced in tandem⁷. Desjardins forceps are inserted via the trancystic ap proach to remove or fragment the stone. If these ma neuvers fail, we perform a choledochotomy to repeat the same instrumental sequence. Conversion is deci ded when the laparoscopic approach fails.

Endoscopic technique: patients with severe cholangitis undergo ERCP pre-cut papillotomy and a plastic stent is implanted without removing the stones⁸. Once the infection has solved, cholecystectomy with exploration of the bile duct is scheduled.

Results

Between March 2018 and March 2020, 881 patients with calculous biliary disease were admitted to our department; 188 of them had choledocholithiasis. Eight patients (0.9%) met the inclusion criteria, 5 during IOC and 3 during ERCP due to severe cholangitis. Six patients were women and 2 were men, mean age was 27 years (range 19-42 years). Mean total bilirubin levels were 8.3 mg/dL (range 6-18 mg/dL).

Of the 5 patients who were initially managed by laparoscopy, 2 cases were resolved by TCI with insertion of the Dormia basket in tandem. In the other 3 patients, the laparoscopic approach failed and required conversion to open surgery. In two patients the stone could be removed and primary closure of the common bile duct (PCCBD) was feasible, while the stone could not be cleared in the remaining patient who required hepaticojejunostomy.

In the 3 patients with severe cholangitis initially managed with endoscopic biliary drainage a 7/10 French plastic stent was introduced and the stone was mobilized to the dilated area of the common bile duct. The patients progress was satisfactory and once the infection resolved within 7 to 10 days, laparoscopic cholecystectomy was performed; the stone and the stent were removed with Dormia baskets by TCI in all the cases. Table 1 summarizes the results.

There were no complications in the 5 patients treated with the TCI and they were all discharged 24 hours later. The two patients converted with PCCBD were discharged after 72 hours. One of them presented biliary leak with low output drainage (< 100 mL/day) and the drain tube was removed on postoperative day 7. The patient requiring HJ was discharged 96 years later. There were no deaths in the series. Operative time varied according to the procedure performed and is shown in Table 2.

Discussion

In the surgical and endoscopic literature, difficult choledocholithiasis is defined as stones impacted in the common bile duct^5,6,8-11. The incorporation of high-cost technology based on direct visualization of the stone (choledochoscopy) and holmium laser lithotripsy, which are not available in most surgical centers^11-14, is necessary to improve the success rate. For this reason, the use of stone fragmentation is limited in a highly prevalent condition such as choledocholithiasis.

Our experience gave us the opportunity to recognize some preoperative and intraoperative features of these patients.

The reason for consultation is usually pain in the right hypochondriac region, followed by jaundice and progressive increase in total bilirubin levels (> 7 mg/dL).

Magnetic resonance cholangiopancreatography could be useful for diagnosis, as it shows the location of the stone with proximal dilatation and distal narrowing of the common bile duct¹⁵; however, as it is not a dynamic study, it cannot predict the behavior of the stone during surgery (Fig. 1A).

Figure 1 A: Magnetic resonance cholangiopan creatography showing a stone in the dis tal common bile duct (white arrow) with proximal dilatation and narrowing of the bile duct distal to the stone (ATCBDO: acute total common bile duct obstruction syndrome). B. ERCP (endoscopic retro grade cholangiopancreatography) with mobilization of the stone (black arrow) to the dilated zone, and stent implant (arrow heads) 

The failure rate of patients treated with a single-stage strategy by laparoscopy was higher than the usual one¹⁶. Failure of the TCI was followed by failure of choledochotomy in all the cases with indication of conversion to open surgery. This is not due to the size of the stones (the cystic duct to stone size ratio was always > 1)¹⁷, but rather to the impossibility of advancing the instruments distal to the stone. The two cases solved by TCI required the in tandem maneuver.

The success rate of laparoscopy in the group of patients who required ERCP with stent placement was similar to the usual success rate; all of these cases were resolved by TCI with Dormia basket. This initial experience makes us believe that probably this type of common bile duct stones could benefit from a two-stage approach or by intraoperative ERCP, which pushes the stone into the dilated proximal bile duct, with placement of a plastic stent to prevent stone reimpaction, allowing for stone and stent removal by TCI in a second stage (Fig. 1B).

If this strategy is validated in larger studies, the resolution of complex cases would help surgeons and endoscopists, thereby avoiding the use of expensive instruments with low availability. Considering the low prevalence of this type of choledocholithiasis, multicenter, prospective, and randomized studies will be necessary.

Conclusion

The management of these patients either by endoscopy or surgery is difficult. Based on our initial experience we believe that these patients could benefit from a two-stage approach or with intraoperative ERCP, if available.