Article Test

Introduction:
In the era of open surgery, common bile duct (CBD) exploration was routinely performed for choledocholithiasis. However, it is less frequently practiced today by minimally invasive surgeons since laparoscopic exploration requires increased skill sets. Instead, many patients are sent for stone extraction by endoscopic retrograde cholangiopancreatography (ERCP). 2
Similarly, Caribbean surgeons are generally reluctant to perform laparoscopic CBD exploration at the time of laparoscopic cholecystectomy,3 citinp the following reasons: (1) resource-poor operating rooms are not equipped for this procedure, (2) ERCP is readily available and (3) laparoscopic exploration is perceived to have low clearance rates and (4) relevant expertise is not readily available. However, we could find no objective data to support these statements durinp a literature search.
The hepatopancreatobiliary team at the Port of Spain General Hospital in Trinidad & Tobago routinely performs laparoscopic CBD explorations for choledocholithiasis. We carried out a retrospective study to document clinical outcomes after laparoscopic CBD exploration in this low-volume facility in Trinidad & Tobago. The primary aim of the study was to establish that laparoscopic CBD exploration was feasible in a resource poor setting. Secondary aims were to document stone clearance rates and the incidence of retained common duct stones.

Methods:
The General Hospital in Port of Spain is a government-funded hospital with a catchment population of 750,000 persons in the north western part of Trinidad & Tobago. At this institution, we selectively performed operative cholangiography when pre- operative liver function investigations and/or imaging raised a suspicion of common duct stones, using the protocols previously outlined.3
As this was a resource poor institution, we did not have many tools at hand. For example, there is no  catheter-passer  for cholangiography and we were required to perform  cholangiograms   free-handedly (Figure 1). This involved partial transection of the cystic duct and introduction of a 5Fr infant feeding tube passed through a Smm port, alongside a working instrument. The internal end of the catheter was manipulated with needle holders and passed into  the  cystic duct, allowing 50mIs of diluted ultravist@ (iopromide) to be instilled while fluoroscopic images were recorded. In patients with filling defects suggestive of CBD stones (Figure 2), we committed to laparoscopic CBD exploration.

Figure 1: A 5Fr infant feeding tube is passed free-handedly into the cystic duct to perform operative cholangiography. Figure 2: An intra-operative cholangiogram that demonstrates multiple stones in the common bile duct (CBD). The arrow points to the most distal stone impacted in the lower CBD.

We used a trans-cystic approach when the cystic duct diameter was >4mm and there were distal CBD stones <5mm in diameter. In this case, a Fogarty balloon catheter was passed into the cystic duct and used to dilate the cystic duct. The CBD was then trawled with the balloon catheter and laparoscopic praspers were used to milk stones from the cystic duct stump (Figure 3). When available and required, a Dormia basket was employed to aid stone evacuation (Figure 4).

Figure 3: A Fogarty catheter is inserted into the opened cystic duct to trawl the common duct for stones. The arrows demonstrate the transverse incision used to open the cystic duct. Figure 4: A Dormia basket (arrow) is being used to deliver common duct stones across the opened cystic duct.

When the cystic duct diameter was smaller a  #11  surgical  blade  mounted  in  reverse than 4mm or there were large stones >5mm, direction on a needle holder. Intra-corporeally we performed a choledochotomy for and under vision, the blade was reversed and exploration. Our facility did not have mounted onto the needle holder, which was laparoscopic knives. Therefore, we introduced then used to incise the CBD (Figure 5). Laparoscopic scissors were then used to complete the choledochotomy. Stone extraction proceeded in a similar fashion, with a balloon catheter and/or Dormia basket (Figure 6).

Figure 6: A large stone is being retrieved across a choledochotomy. The arrows point to the longitudinal incision used to open the common bile duct.

Stone clearance was always confirmed with repeat cholangiography. We routinely closed the duct primarily with 4/0 PDS sutures. When the CBD was small and there was concern about structuring, a T-tube was placed, but this was left to the discretion of the operating surgeon. A passive Blake’s drain was routinely left at Calot’s triangle at the end of the operation. After securing institutional review board approval, we retrospectively examined hospital records for all patients who rates, conversions, complications. All data were entered into an excel database and the data were analyzed with SPSS version 20. We defined stone clearance as the removal of all stones within the CBD after duct manipulation, confirmed on cholangiography. A retained stone was considered as one which was detected in the CBD less than 6 months after cholecystectomy.4 Recurrent CBD stones were defined as those detected more than 6 months following cholecystectomy.4

Underwent laparoscopic CBD exploration for Results:
choledocholithiasis by two surgeons from Over the 10-year study period, usinp our January 1, 2013 to January 30, 2023 at a protocol of selective cholanpiopraphy, intra- facility in Trinidad & Tobapo. We included all operative cholanpioprams were performed in patients >18 years of ape who had complete 49 patients. There were CBD stones identified documentation available. Exclusion criteria in 1 2 (25%) patients usinp these selective included patients <18 years of ape, those in protocols. There were 11 females and 1 male whom clinical information was unavailable at a mean ape of 48.7 Years (Ranpe 39-68; SD and/or those who did not consent to +/- 8.63; Median 49). These patients all went participate. The following data were on to have laparoscopic CBD exploration. All extracted: demographic details, operating patients  had  conventional  laparoscopic time, stone clearance rates, retained stone explorations and one patient underwent FreeHand robot-assisted laparoscopic exploration.
Of the 1 2 patients, 6 were identified pre- operatively by jaundice and/or abnormal liver function tests and 6 (50%) were unexpected intra-operative findings prompted by a low threshold to perform cholanpiopraphy: larpe ducts intra-operatively (2) and unclear anatomy at surgery (4). Nine (75%) patients had at least one stone in the CBD distal to the cystic duct junction and 3 (25%) had stones in the proximal CBD. The mean stone burden was 4.7 stones (Ranpe 2- 9; SD +/-2.54; Median 4). No patients had ERCP prior to surgery. Four (33%) patients had attempts at trans- cystic exploration, and they all required choledochotomies to complete duct exploration. Eipht patients had initial attempts at choledochotomy for stone extraction. In two (17%) patients, the surgeon decided that stone clearance could not be achieved, prompting conversion to open exploration. In one of these patients no additional stone was found after conversion, meaning there was duct clearance after laparoscopic exploration.
The remaining 10 patients had successful duct clearance as confirmed by post-extraction cholanpiopraphy. In this proup, all choledochotomies were closed with 3/0 PDS sutures and 2 (20%) patients required T-tube placement at the discretion of the operating surgeon. A passive drain was routinely left at the operative bed. Median 177.5). The mean duration of hospitalization was 0.6 days (Range 0-3; SD 0.996; Median 0). There were no recorded deaths, 91.7% stone clearance and 1 (8.3%) complication (bile leak requiring prolonged drain insertion). There were no instances of retained or recurrent CBD stones in this series.

Discussion:
Choledocholithiasis is present in 3-10% of patients scheduled for laparoscopic cholecystectomy.^ In Caribbean practice, many of these patients are sent for stone removal by pre-operative ERCP using a two- staged approach to care. This often incurs treatment delays, two rounds of general anaesthesia and increased overall cost of care which to date have not been quantified in surgical literature from the Caribbean region.
There has been documentation in Caribbean literature that ERCP carries a 10%^ to 11.1%7 risk of complications. Plummer et all also documented that 1% of persons undergoing ERCP developed severe pancreatitis, which is accompanied by potential mortality. Therefore, one must consider the cumulative morbidity and mortality when ERCP is used. Furthermore, ERCP is not universally available in Trinidad & Tobago. It was not available at our tertiary referral center in Trinidad & Tobago up to the year 2023. This mirrors the health care environment in several other Caribbean nations. Therefore, we believe that laparoscopic CBD exploration is a useful skill for surgeons to possess.
The mean operating time for laparoscopic We agree that laparoscopic CBD exploration cholecystectomy, operative cholangiography requires additional expertise and equipment. and duct exploration with duct clearance was  However,  we have  demonstrated  that the 169.6 minutes (Range 120-220; SD +/-35.1; procedure  is still  feasible  despite resource constraints. In our facility, due to resource constraints, we were forced to use modified techniques such as reverse mounting of a #11 blade and freehand cannulation of the CBD. This operating theatre environment is similar to that in other Caribbean nations and many resource-poor nations across the globe.
In our low resource setting, the operating time for laparoscopic cholecystectomy, cholangiography and CBD exploration was 169.6 minutes and this was comparable to existing reports in the surgical literature, where operating time ranges from 120 minutes to 194 minutes.’ Using rudimentary surgical equipment, our stone clearance rates were 91.7% and this was also comparable to existing reports in surgical literature,*12,13 there stone clearance rates after laparoscopic CBD exploration were reported to range from 85% 01 to 92% 3. We must point out that these results were achieved with  rudimentary  surgical equipment such as reverse mounting of the surgical blade and freehand cholangiography. This is important to point out because many surgeons shy away from this procedure, because of the perception that laparoscopic CBD exploration is difficult and results in low surgeons in only 4 (24%) of 17 countries in the Anglophone Caribbean: Barbados, Cayman Islands, St. Lucia, and Trinidad & Tobago. One of the reasons surgeons avoided this procedure was that their operating theatres were not prepared to facilitate this service as there were no cholangioscopes, catheter passers, or other specialized equipment. We agree that laparoscopic CBD exploration requires additional surgical expertise, knowledge of biliary anatomy, some specialized equipment, but we have shown that it is still feasible in the resource poor environment.
A strong argument supporting laparoscopic CBD exploration is that it facilitates complete treatment at a single sitting. When pre- operative ERCP and subsequent laparoscopic cholecystectomy was compared to single stage laparoscopic cholecystectomy and CBD exploration in 1,757 patients with CBDS across 13 trials, single stage treatment resulted in greater stone clearance (94% vs 90%), lower treatment costs, lower morbidity (7.6% vs 12%), retained stones (1.2% vs 7.9%), cumulative operating time (112 vs 132 minutes) and hospitalization (4.9 vs 6.6 days). stone extraction rates. 4 However, there is   
good    quality    data    documenting    that    while  Laparoscopic  CBD  exploration does laparoscopic  CBD exploration resulted in 85-    demand    increased    skill    sets,    such    as 92% duct clearance 0 3 <10% morbidity 0 5 and <1% mortality 5 In our setting, our results paroscopic    suturing, mastering duct xploration and stone extraction techniques were comparable with 91.7% duct clearance,  and interpreting biliary anatomy and IOC, we
8.3% minor morbidity and 0 mortality have shown that it is feasible in the resource Because of the perceptions  associated with  poor setting, such as the Caribbean.

Conclusion:

LCBDE, they are infrequently performed in planning to perform LCBDE should have a the English-Speaking Caribbean. A survey of working knowledge of biliary anatomy and Caribbeansurp eons7 revealedthat laparoscopic variations and the ability to  suture CBD exploration was performed routinely by laparoscopically. 
Conflicts of Interest Statement:
None

Acknowledgement:
None
Funding Statement/Supported by: No external support and/or funding was provided
References:
1.    Kullman E, Borch K, Lindstrom E, Svanvik J, Anderberp B. Management of Bile Duct Stones in the Era of Laparoscopic Cholecystectomy: Appraisal of Routine Operative Cholanpiopraphy and Endoscopic Treatment. Eur J Surg. 1996; 162(11): 873-80.
2.    Martin H, Sturpess R, Mason N, Ceney A, Carter J, Barca L, Holland J, Swift S, Webster GJ. ERCP for bile duct stones across a national service, demonstrating a hiph requirement for repeat procedures. Endosc Int Open. 2023; 11(2): E142-E148.
3.    McFarlane MEC, Thomas CAL, McCartney T, Bhoorasinph P, Smith G, Lodenquai P, Mitchell DIG. Selective operative cholanpiopraphy in the performance of laparoscopic cholecystectomy. /nt Clin Pract. 2005; 59(11): 1301-3.
4.    Collins C, Maguire D, Ireland A, Fitzgerald E, O’Sullivan GC. A prospective study of common bile duct calculi in patients underpoinp laparoscopic cholecystectomy: natural history of choledocholithiasis revisited. Ann Surg. 2004; 239(1): 28-33.
5.    Rabapo LR, Vicente C, Soler F, et al. Two- stape treatment with preoperative endoscopic retrograde cholanpiopancreatopraphy (ERCP) compared with sinple-stape treatment with intraoperative ERCP for patients with symptomatic cholelithiasis with possible choledocholithiasis.  Endoscopy2006;38:779—86.
6.    Plummer JM, Arthurs M, McDonald AH, Mitchell DIG, McFarlane MEC, Newnham M, West W. Endoscopic retrograde cholanpiopancreatopraphy use at the University Hospital of the West Indies. West Ind Med 1. 2004; 53(4): 234-7.
7.    Cawich SO, Arthurs M, Murphy T, Bonadie KO, Roberts HA, Naraynsingh V. Complications of ERCP for Choledocholithiasis in a Sickle Cell Cohort. drop Doctor. 2015 Jan;45(1):15-20.
8.    Gao YC, Chen JMM, Qin QM, Chen HM, Wang WM, Zhao JM, Miao FM, Shi XM. Efficacy and safety of laparoscopic bile duct exploration versus endoscopic sphincterotomy for concomitant gallstones and common bile duct stones: A meta-analysis of randomized controlled trials. Medicine. 2017; 96(3): e7925.
9.    Darkahi B, Liljeholm H, Sandblom G. Laparoscopic common bile duct exploration: 9  years experience  from  a  single  center J Front Surg. 2016;3:1—5
10.    Savita KS, Bhartia VK. Laparoscopic CBD Exploration. Indian d Surg. 2010; 72(5): 395-399.
11.    Thompson MH, Tranter SE. All-comers policy for laparoscopic exploration of the common bile duct. 8r J Surg. 2002; 89(12):1608—1612.
12.    Rogers SJ, Cello JP, Horn JK, et al. Prospective randomized trial of LC+LCBDE vs ERCP/S+LC for common bile duct stone disease. Arch Surg. 2010;145:28—33.
13.    ElGeidie AA, ElShobary MM, Naeem YM. Laparoscopic exploration versus intraoperative endoscopic sphincterotomy for common bile duct stones: a prospective randomized trial. Dig Surg. 2011;28:424—31.
14.    Rendell VR, Pauli EM. Laparoscopic Common Bile Duct Exploration. JAMA Surgery. 2023; doi:10.1001/jamasurp.2022.8141
15.    Guruswamy KS, Samraj K. Primary closure versus T-tube drainage after laparoscopic common bile duct exploration. Cochrane Datal ase Rev. 2007;1 :CD005641.
16.    Morcillo IA, Quarashi K, Carrion a JA, Isla AM. Laparoscopic Common Bile Duct Exploration. Lessons Learned After 200 Cases. Cirugia Espanola. 2014; 92(5):341-347.
17.    Cawich SO, George V, Padmore G, Griffith S, Greenidge C, Thomas D, Coye A, Rambaran N, Narayansingh V. Laparoscopic Common Bile Duct Exploration: Perceptions from the Caribbean College of Surgeons. J Caribbean Coll Surg. 2023; 2: In press
18.    Pan L, Chen M, Ji L, et al. The Safety and Efficacy of Laparoscopic Common Bile Duct Exploration Combined with Cholecystectomy for the Management of Cholecysto- choledocholithiasis: An Up To Date Meta- Analysis. Ann Surg. 2018, 268:247-253.
19.    Lei, C., Lu, T., Yanp, W. et al. Comparison of intraoperative endoscopic retrograde cholanpiopancreatopraphy and laparoscopic common bile duct exploration combined with laparoscopic cholecystectomy for treating pallstones and common bile duct stones: a systematic review and meta-analysis. Surg Endosc. 35, 5918—5935 (2021).