Transcript Management of the Abnormal Cholangiogram

Fanelli
Laparoscopic Endobiliary Stent
Robert D. Fanelli, MD, FACS
Assistant Professor of Surgery
University of Massachusetts Medical School
Director of Surgical Endoscopy
Berkshire Medical Center
Laparoscopic Endobiliary Stent Placement
Eliminates need for T-tubes, cystic duct catheters, external drains
when Laparoscopic Transcystic Common Bile Duct Exploration
(LTCBDE) or Laparoscopic Common Bile Duct Exploration
(LCBDE) performed
Eliminates need for LTCBDE or LCBDE for Common Bile Duct
Stones (CBDS)
Protects ductal closures, limits risks of bile leak
Fanelli Laparoscopic Endobiliary Stent
Laparoscopic Endobiliary Stent Placement
Prevents complications associated with retained CBDS
Virtually assures success of postoperative ERCP
Necessary equipment inexpensive, readily available
Suitable for use in ASCs as well as hospitals
Fanelli Laparoscopic Endobiliary Stent
Laparoscopic Endobiliary Stent Placement
First described as adjunct to LCBDE,
eliminating T-tubes
16 patients (1993-1995)
100% clearance CBDS by LTCBDE
and LCBDE
No bile leaks, complications
36 to 72 hour LOS
Gersin, Fanelli.Surgical Endoscopy, vol.12 (4),April 1998 p. 301.
Fanelli Laparoscopic Endobiliary Stent
Laparoscopic Endobiliary Stent Placement
Most surgeons rely on postoperative ERCP for CBDS
Patients face risks of retained CBDS, pancreatitis, cholangitis,
stump leak
ERCP results vary based on volume

High volume centers, > 95% selective cannulation rate

Low volume centers, < 60% selective cannulation rate

Average rates of selective cannulation, 80 to 85%
20% patients face reoperation, PTC, or referral for second ERCP
for CBDS left at time of LC
Conversion, T-tubes, drains deprive patients of low morbidity, quick
recovery of LC
T-tubes, drains require constant management, delay discharge
Fanelli Laparoscopic Endobiliary Stent
Laparoscopic Endobiliary Stent Placement
Our current experience (SSAT Scientific Session, May 2000)
372 consecutive LC during 36 months, ending July 1999
Hasson cannula, three 5 mm upper abdominal ports, general
anesthesia, CO2 insufflation, routine fluorocholangiography (FC)

FC accomplished in all patients

CBDS or suspicious FC identified in 48 (12.9%)
No attempt made to clear CBDS, all patients treated with stents
Stent placement added 9 to 26 minutes to LC operative time
Cystic duct balloon dilation necessary in 14 (29.2%)
Laparoscopic suturing, advanced skills were not utilized
Fanelli Laparoscopic Endobiliary Stent
Laparoscopic Endobiliary Stent Placement
Hemorrhage, bile duct injury, duodenal perforation, sub-optimal
stent placement, stent migration did not occur
Longest f/u 46 months; original series, 80 month f/u
44 (92%) treated as outpatients
4 (8%) admitted overnight with average LOS 30 hours

Indications for admission:

PONV (2)

surgery completed too late for discharge (1)

weather too severe for safe discharge (1)
Outpatient ERCP with ES 1 to 4 weeks later

100% successful for clearance of CBDS

CBDS found in all patients -- no false positive FC

No ERCP, stent related complications to date, including pancreatitis
Fanelli Laparoscopic Endobiliary Stent
Laparoscopic Endobiliary Stent Technique
Routine FC via epigastric port
Flexible tip cholangiogram catheter
with three-way adapter
Three-way adapter permits saline,
contrast injection, and placement
of wire guide
Fanelli Laparoscopic Endobiliary Stent
Laparoscopic Endobiliary Stent Technique
150 cm Tracer Hybrid® Wire Guide
advanced through cholangiogram
catheter
Wire guide positioned across
ampulla, past CBDS
Cholangiogram catheter, removed
over wire guide
Finger occlusion of epigastric port
prevents loss of CO2
Stent introducer port can be used
if desired
Cystic duct dilated if necessary
Fanelli Laparoscopic Endobiliary Stent
Laparoscopic Endobiliary Stent Technique
Continuous fluoroscopy
Stent assembly advanced over wire
guide
Position stent across ampulla
Radiographic markers assure
proper positioning
Stent is fixed to delivery
mechanism
Stent location adjusted as needed
prior to deployment
Once position perfect, release
safety to prepare for deployment
Fanelli Laparoscopic Endobiliary Stent
Laparoscopic Endobiliary Stent Technique
Radiographic markers

Marker 1 - distal tip

Marker 2 - distal flange

Marker 3 - proximal flange

Marker 4 - proximal tip
Markers signal deployment


Markers 3, 2, and 1 pass through
4 during release
After 3, 2, and 1 clear 4, stent is
free of delivery system
Fanelli Laparoscopic Endobiliary Stent
Laparoscopic Endobiliary Stent Technique

Stent successfully deployed

Positioned across ampulla

Contrast rapidly drains from CBD

Cystic duct ligated

Cholecystectomy completed

Drains are not placed

Patient is discharged when alert
Placement of stent added 20
minutes to LC operative time
Fanelli Laparoscopic Endobiliary Stent
Laparoscopic Endobiliary Stent Technique
ERCP 1 to 4 weeks postop

Same admission feasible
Various ERCP methods




Snare removal of stent prior to
cannulation, sphincterotomy
Wire guide placed via stent prior
to retrieval
Precut sphincterotomy over stent
Cannulate beside stent for
sphincterotomy
(preferred method)
Fanelli Laparoscopic Endobiliary Stent
Laparoscopic Endobiliary Stent Kit
Stent and pusher assembly
150 cm Tracer® Hybrid Wire Guide
Additional Components

Introducer set

12 French cystic duct dilation balloon

Cholangiogram catheter with three-way adapter, short wire
Fanelli Laparoscopic Endobiliary Stent
Conclusions
There are numerous methods for treating CBDS during LC
LCBDE is quick and highly successful, but requires refined laparoscopic
suturing skills and carries risks of choledochotomy
LTCBDE is time consuming, requires expensive equipment and
endoscopic, fluoroscopic skills, but avoids choledochotomy
Both employ external drains, T-tubes, or cystic duct catheters
Laparoscopic stent placement is fast, involves minimal expense,
does not require choledochotomy, eliminates external tubes and
drains, and virtually assures success of postoperative ERCP
Fanelli Laparoscopic Endobiliary Stent
References
Gersin KS, Fanelli RD. Laparoscopic Endobiliary Stenting as an
Adjunct to Common Bile Duct Exploration. Surg Endosc 1998
Apr;12(4):301-304.
Fanelli RD, Gersin KS. Laparoscopic Endobiliary Stenting: A
Simplified Approach to the Management of Occult Common Bile Duct
Stones. J Gastrointest Surg 2001 Jan/Feb; 5(1):74-80.
Fanelli RD, Gersin KS, Mainella MT. Laparoscopic Endobiliary Stenting
Significantly Improves Success of Postoperative ERCP in Low Volume
Centers. Surg Endosc 2002 Mar;16(3):487-491.
Wu JS, Soper NJ. Comparison of Laparoscopic Choledochotomy
Closure Techniques. Surg Endosc 2002 Sep;16(9):1309-1313.
Fanelli Laparoscopic Endobiliary Stent