LAPAROSCOPIC MANAGEMENT OF COMMON BILE-DUCT STONES - A MULTIINSTITUTIONAL SAGES STUDY

Laparoscopic common bile duct exploration (CBDE) was the subject of a multi-institutional study on 226 patients from 19 major hospital cente rs. Female patients predominated (2.3: 1); the average age was 54; 75% of cases were chronic, and the remainder were acute. Although 97% had preoperative ultrasonograms, only 12% showed a stone in the dilated c ommon bile duct. The alkaline phosphatase was elevated in 41% and the serum bilirubin in 28% of cases. Preoperative endoscopic retrograde ch olangiography with sphincterotomy (ERC-ES) was performed in 8.5%; ther e was a successful stone extraction in less than half the cases. Chola ngiography was performed in 99.5%, and in 94% of those cases, stones w ere found. In 83% of cases, stones were removed through the transcysti c approach, and in 17% removal was throughout the CBD. In the majority of cases, the choledochoscope and wire basket (34%), irrigation (33%) , or a combination of both was employed. In the transcystic group, 5% were converted to open procedures due to technical difficulty, as cont rasted with the trans-CBD route, where the conversion rate was 19%. Th ere were two ductal injuries. Minor complications occurred in 5.7% wit hin 24 h; there was one death (0.4%). Within 30 days, the morbidity ra te was 7% and there were no deaths. Retained stones were discovered in 2.6% of cases. Laparoscopic CBDE is a feasible approach for CBD stone s which permits a definitive procedure in one stage, without pre- or p ostoperative ES. It is a skill which should be mastered by the biliary surgeon. Further improvement in instrumentation and technique should make the laparoscopic approach not only comparable but preferable to t he standard open choledocholithotomy.