Donald E. Wenner MD
Abstract
Introduction: ERCP with sphincterotomy has become the dominant means used to clear stones from the CBD in the laparoscopic era. The ERCP procedure has been plagued by pancreatitis in 10% of cases and severe pancreatitis in 1% of cases. LCBDE has been shown in controlled studies to be as effective as or more effective than ERCP. LCBDE also results in shorter hospital stays, and is more cost effective. This study was undertaken to evaluate the risk of precipitating pancreatitis during LCBDE using the 2.8 mm flexible choledochoscope.
Method: Data was collected on 68 consecutive patients undergoing LCBDE using a 2.8mm flexible choledochoscope. The choledochoscope was guided into either the cystic duct or CBD using the MIG (multi-channel instrument guide). Stones were manipulated and the bile duct inspected using video imaging. Irrigation, stone baskets, balloon catheters, and lithotripters were used. Balloon dilation of the Ampulla was not done. Balloon catheters, choledochoscope and stone baskets were frequently passed through the Ampulla. Stone baskets were not pulled through the Ampulla in the open configuration.
Results: The postoperative amylase level was significantly lower than the preoperative level (paired T-test, p= 0.05). No case of clinical pancreatitis developed in any of these patients as a result of the LCBDE procedure.
Discussion: Laparoscopic cholecystectomy with IOC carries less risk to the patient than ERCP/sphincterotomy. Preoperative ERCP based on the clinical suspicion of choledocholithiasis should be abandoned. LCBDE techniques are evolving, and our technique using the 2.8 mm video choledochoscope, the MIG, stone baskets, irrigation, balloon catheters, and lithotripsy devices has been shown to be effective in virtually all cases of choledocholithiasis, and not to cause the dreaded complication of pancreatitis. All laparoscopic biliary surgeons need to be trained in LCBDE.