The aim of this study is to compare between the outcome of management of concomitant gallstones and common bile duct by two stage (ERCP+LC) versus one stage(LECBD+LC) as regard: Intraoperative complications Conversion to other procedure Total operative time Postoperative complications Postoperative mortality Retained CBD stones Length of hospital stay Patient satisfaction

1. Single-stage laparoscopic
management for concomitant
gallstones and common bile
duct stones versus two stages
using ERCP procedures
PRESENTED BY/
DR. MOHAMED TAG ELDIN MOHAMED SAYED
MD RESEARCHER SOHAGE UNIVERSITY HOSPITAL
GENERAL SURGERY SPECIALIST QENA GENERAL HOSPITAL

2. Introduction
 About 10–15% of patients with gallstones present with
concomitant common bile duct stones.
 Of more concern is the management of these CBD
stones, which had been debated for years since the
introduction of laparoscopic cholecystectomy in the late
1980s.
( Chester Tan et al, 2018)

3.  Management strategy of common duct stones
involves either endoscopic common duct
clearance followed by removal of the
gallbladder surgically or surgical exploration
and clearance of the CBD. Surgical exploration
can be done by open choledocholithotomy or
laparoscopically.
( Kadam R et al, 2017)

4.  Endoscopic stone extraction followed by laparoscopic
cholecystectomy (ERCP + LC) was the standard of
care for patients with gall stones and CBD stones.
 However, with increasing expertise in laparoscopic
procedures, more and more surgeons have started
offering a single-stage laparoscopic CBD exploration
and cholecystectomy (LCBDE) to patients.
(Singh, A.N. & Kilambi, R.,2018)

5.  At present, it is really equivocal with the handful
evidence that whether or not two-stage
management is preferable to or otherwise
comparable to the one-stage operative procedure
for CBD stones.
(Pankaj Prasson et al, 2016)

6. Aim of Work
 The aim of this study is to compare between the outcome of
management of concomitant gallstones and common bile duct
by two stage (ERCP+LC) versus one stage (LECBD+LC)

7. Patients and Methods
 This study included 150
patients with concomitant
gallstones and CBD stones who
were treated at Sohag
University hospital from July
2017 to December 2018.

8. Criteria for inclusion
Age 16 to 70 years.
Patients with or without Jaundice.
Patients with gallbladder stones and concomitant
stones in the CBD.
CBD diameter ≥1cm.

9. Criteria for exclusion
 Acute cholecystitis.
 Acute pancreatitis.
 Uncorrectable coagulopathy.
 Liver cirrhosis, intrahepatic gallbladder, liver mass or
abscess, neoplasm.
 Recurrent CBD stones.
 Malignant pancreatic or biliary tumors.

10.  Group A (75 patients) underwent single-stage laparoscopic
CBD exploration (LCBDE) and laparoscopic cholecystectomy
(LC).

11.  Group B (75 patients) underwent a two-stage procedure;
ERCP for endoscopic extraction of CBD stones followed by
LC (ERCP + LC) within the same hospital admission.

12. Results

13. Group A (LCBDE)
Trocar arrangement
Sometimes, direct puncture for the basket or facial closure
forceps retractionTrocars are applied as that for cholecystectomy

14. The item Number Percent
Trans-cystic approach 8 10.6%
Trans-choledochotomy approach 67 89.4%
Choledochoscopic technique 45 60%
Cholangiogram 22 29.3%
Direct access 8 10.7%
Total 75 100%

15. Trans-cystic approach Incision of the
cystic duct

16. Ureteric catheter cannulation of cystic
duct

17. Contrast injection (diluted urographine
solution)

18. Trans-cystic basket extraction of the
CBD stone

19. Trans-choledochotomy approach
Dissection of cystic/hepatic duct communication

20. Choledochotomy using protected Scalpel

21. Choledochotomy using protected diathermy
hook

22.  The choledochoscope used (Pentax
choledochoscope)

23. Choledochoscope is manipulated through
choledochotomy to CBD lumen using
atraumatic grasper

24. CBD stones as visualized by the
choledochoscope within CBD

25. Through choledochoscope basket extraction of the CBD
stone to outside CBD

26. Proximal assurance of CBD clearance by
choledochoscope

27. Direct stone manipulation by basket through
choledochotomy without Choledochoscopy

28. Stone extraction by direct access
without choledochoscope help

29. T-tube application

30. T-tube deployment through CBD lumen

31. Choledochal suturing above and below
T-tube choledochotomy

32. Choledochorrhaphy and primary CBD
closure

33. Primary closure using V-lock suture

34. Postoperative view

35. Group B (ERCP+LC)
ERCP Scope

36. ERCP- balloon extraction

37. ERCP- Basket extraction

38. ERCP- balloon and basket extraction

39. ERCP multiple stone extraction

40. ERCP- Lithotripsy

41. Laparoscopic Cholecystectomy

42. Postoperative view

43. Comparison in
• Intraoperative complications
• Conversion to other procedure
• Total operative time
• Postoperative complications
• Postoperative mortality
• Retained CBD stones
• Length of hospital stay
• Patient satisfaction

44. Group A (LCBDE) Group B (ERCP+LC)
Success rates for clearance of CBD 97.3% 98.7%
Intraoperative complications 1.3% hemorrhage 2.6% hemorrhage during Lap.
Cholecystectomy
Conversion to other procedure 2.6% 4% (conversion of lap.
Cholecystectomy to open)
Total operative time 115.7 ± 36.6 min 82.4 ± 27.6 min
Postoperative pain • 24h: 3.4 ± 1.7 (rang 1-7)
• 3days: 0.6 ± 0.9(rang 0-2)
• 24h 4.8 ± 1.8 (rang 2–7)
• 3days 0.7 ± 0.8 (rang 0–3)
Postoperative complications Transient bile leak 6.6% • Transient bile leak 2.6 %
• Acute pancreatitis 5.3%
Postoperative mortality Nil Nil
Retained CBD stones 2.6% Nil
Length of hospital stay 4.6 ± 2.4 days 5.3 ± 6.2 days
Patient satisfaction 1.62 ± 0.3(rang 1-5) 1.94 ± 0.7(rang 1-7)

45. Summary
 The success rates of laparoscopic CBD exploration and ERCP for
clearance of CBD were comparable.
 The mean operative time was significantly longer in-group A but the
overall hospital stay was significantly shorter.
 As regard intraoperative complications there were no significant
difference between Group A(1.3% hemorrhage) vs. group B (2.6%
hemorrhage).
 As for conversion to other procedure for group A less than for group B
but statically insignificant.

46.  Post-operative pain recorded in group A less than group B but statically
insignificant.
 Postoperative complications rates between the two groups were
comparable, Group A showed (Transient bile leak 6.6%) vs Group B
(Transient bile leak 2.6 %, Acute pancreatitis 5.3%).
 Two patients (2.6%) in-group A had a diagnosis of retained stones
determined during follow up.
 The patients in-group A had higher satisfaction scores than the patients
in-group B.

47. Conclusions
 Single and two-stage management for uncomplicated
concomitant gallbladder and CBD stones had similar success
and complication rates, but the single stage strategy was
better in terms of shorter hospital stay, need for fewer
procedures, less morbidity, and allows earlier recovery with a
reduced period of short-term disability.

48. Thank you all
with special thanks to my senior
supervisor
Prof. Alaa Redwan
Professor of GIT surgery and
laparoendoscopy
Faculty of medicine, Sohag University