Use of rigid nephroscope in open common bile duct exploration--our experience.
Gall bladder stones and Common Bile Duct (CBD) stones affect significant proportion of human population. About 15% of people with gallstone develop stones in the Common bile duct. (1) The incidence is even higher in older ages and 20 to 25% of patients older than 60 who have gallstone disease present with concurrent choledochal stones. It may result in complete or incomplete bile duct obstruction and manifest with cholangitis or gallstone pancreatitis. (2) Choledocholithiasis is one of the medical conditions leading to surgical intervention. It is managed either by endoscopic sphincterotomy or surgical exploration.
Despite advancements in gall bladder surgery with the introduction of endoscopic and laparoscopic technique, many surgeons, especially in the developing world, still perform open cholecystectomy with CBD exploration for choledocholithiasis. (3)
Traditionally, CBD stones are retrieved with Desjardin forceps through choledochotomy and closed over T-tube, but potential of complications and residual stones exist with this therapeutic modality. These lead to prolonged hospital stay and need again for treatment of residual stone. (4)
In 1991, Petelin et al first described laparoscopic surgery of common bile duct stone. The technique has evolved since then and several studies have concluded that Laparoscopic Common Bile Duct Exploration (LCBDE) procedures are superior to sequential endoscopic treatment. (5) LCBDE is done using flexible choledoschoscope or rigid scopes. Most of them use rigid nephroscope instead of flexible choledoschoscope, getting good results since flexible choledoschoscope is very costly and maintenance is difficult. With the help of this technique of using rigid scope in LCBDE, we present our experience of open common bile duct exploration using rigid nephroscope to assess the feasibility, safety and complete stones clearance in the setting of recently established medical college where no facility for laparoscopic CBDE.
MATERIALS AND METHODS
A total of 30 patients of choledocholithiasis, 25 females and 5 males underwent open CBD exploration after choledochotomy with rigid nephroscope between March 2012 to March 2015 followed by cholecystectomy at the Department of Surgery, JNIMS, Imphal. All the patients were investigated. As a protocol, ultrasound of whole abdomen was repeated in our institute for those patients who were evaluated outside JNIMS. MRCP was done in almost all the patients (Fig. 1).
4 patients had post cholecystectomy choledocholithiasis and 26 patients had cholelithiasis with choledocholithiasis. The minimum duct diameter was 10 mm.
22 patients had preoperative jaundice which was treated with antibiotic, IV glucose, Vitamin K, etc. and taken for surgery after one week.
Intraoperative finding, time taken for surgery and postoperative complications were taken into consideration.
All the patients were operated through right sub-costal incision. After choledochotomy, the rigid nephroscope (Fig. 2) is inserted to visualise interior of the bile duct proximally till both the right and left hepatic ducts interior are visible and distally till Ampulla of Vater is visible with continuous irrigation.
Any stones which were found were removed by rigid grasping forceps under direct vision through scope. Some of the stones were fractured and pushed into the duodenum with rigid forceps. Then biliary stent of 7F 10 cm length is inserted and choledochotomy is closed primarily with vicryl 3-0. A subhepatic drain was kept in all the cases, which were removed when there was less than 50 mL serous fluid.
All the patients were routinely given IV third generation cephalosporin for 3 days and converted to oral antibiotic and discharged on 5th postoperative day. They were asked to come after one month for endoscopic removal of biliary stent.
Patient's demographic, intraoperative finding, operative time, duration of hospital stay and post-operative complications were recorded on a Performa.
Of the 30 patients who underwent open common bile duct exploration using rigid nephroscope, 29 patients had secondary stones and only one patient had primary stone formed over the migrated clip following laparoscopic cholecystectomy after 6 years (Fig. 3).
There were 25 females and 5 males with the ratio of 5:1. The age ranges from 15 to 70 years with the mean of 42.5 years.
Majority of the patients have single stone, 5 patients have more than 3 stones and 1 patient has large impacted stone at the distal CBD (Fig. 4 and Fig. 5 and 6)
Stone clearance is 100% and complications related to the procedure were not observed.
Operative time ranged from 70 to 100 minutes with the average of 85 minutes.
There were no intraoperative complications in any of the patients. In all the patients, drain was removed on the 2nd postoperative day and discharged on 4th or 5th post-operative day. None of the patients had any postoperative complications and no morality in our study. Biliary stent was removed after one month by endoscopy. (Fig. 9) No patients had any complaints during the followup.
There is dispute regarding the optimal treatment for concomitant gallstones and CBD stone. (6,7,8) The traditional approaches of open common bile duct exploration have been replaced by newer, less invasive procedures. The principle minimally invasive options in the treatment of CBD stones include ERCP with endoscopic stone extraction and laparoscopic CBD exploration. (9)
However, these minimally invasive approaches are not widely practiced in many developing countries due to the lack of equipment and trained endoscopists. Even in the developed world in rural settings, there is lack of equipment for these techniques. (10) There are several drawbacks of this approach, even though this is effective and safe. Surgeons are often left with no option other than to continue the practice of open CBD exploration due to unavailability of trained Endoscopist in ERCP and lack of skill experience laparoscopic surgeons. Furthermore, a Cochrane database review published in 2006 has suggested that ERCP was less successful than open surgery in CBD stone clearance and was associated with a higher mortality. (11) There is also an increased recurrence rate of CBD stones following endoscopic removal. (10) The success rate for stone clearance is 87% to 97%, but up to 25% of patients require two or more ERCP treatments. (12) ERCP was less successful compared with open surgery in CDB stone clearance.
LCBDE is a demanding technique with a long learning curve, (13) which has replaced open CBD exploration. LCBDE has been proven to be a safe, reliable, effective and single stage procedure for the treatment for CBD stones. LCBDE has become the main treatment for CBD stones associated with cholelithiasis. (14) The UK guidelines recommended LCBDE as the treatment of choice for patient with CBD stones undergoing laparoscopic cholecystectomy. (15) However, successful stone clearance rates for LCBDE range from 85% to 95% with a morbidity rate of 4% to 16% and mortality of 0% to 2%. (16) A major problem for patients who undergo LCBDE by choledochotomy are biliary leakage and biliary stricture. Biliary leakage occurred in only 6% of patients. (17) In our study, common bile duct exploration with the use of rigid nephroscope, rate of stone clearance is 100% without any morbidity and mortality (Fig. 7 and 8).
For many years open CBD exploration has been the main treatment modality for CBD stones. It is also performed frequently at the present time. (18) Our institute is also still performing open CBD exploration, as there is no facility for ERCP and Laparoscopic CBD exploration.
ERCP is difficult for removing a large stone. Open surgery is indicated for large stone and when ERCP fails, for which choledochoscope or any rigid scope is useful and easier to inspect CBD. With the use of mechanical lithotripsy, the success rate for removing CBD stone can be improved even with large or impacted stones. Garg et al, over a 4 years period achieved a success rate of only 79% for removing CBD stone even after using mechanical lithotripsy. (19) Due to limitations of flexible choledoschoscope like high cost and unable to retrieve very big stones, many surgeons using rigid nephroscope with good results. Sarkar et al and Khan et al have shown that rigid nephroscope is superior to flexible choledoschoscope in removing large stones and is cost effective. (20,21) We were also using rigid nephroscope in many patients for open CBD exploration with good results in terms of complete stone clearance without any complications. This instrument is usually available at all surgical centres. It is robust, has large working channel and vision is excellent. One can pass stout forceps through it to remove calculi and thus ensure 100% stone clearance irrespective of size, hardness or degree of impaction of the stone. It has been reported that CBD stone clearance rate of traditional open CBDE is 83.3% to 88.8%. (22,23) Our experience with the use of rigid scope is very encouraging and seems to be safe and highly effective.
Rigid nephroscope can also be used in open common bile duct exploration. It is safe and feasible with the achievement of complete stone clearance without any complication. It is an efficacious procedure in dealing with unsuccessful endoscopic stone extraction and centre having no facility for Laparoscopic common bile duct exploration.
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S. Robindro Singh , S. ShyamchandSingh , T. Tozo Luwang 
 Associate Professor, Department of Surgery, Jawaharlal Nehru Institute of Medical Sciences, Porompat, Imphal, Manipur.
 Assistant Professor, Department of Surgery, Jawaharlal Nehru Institute of Medical Sciences, Porompat, Imphal, Manipur.
 Senior Resident, Department of Surgery, Jawaharlal Nehru Institute of Medical Sciences, Porompat, Imphal, Manipur.
Financial or Other, Competing Interest: None.
Submission 12-09-2016, Peer Review 07-10-2016, Acceptance 12-10-2016, Published 19-10-2016.
S. Robindro Singh, SingjameiSougrakpam Leikai, Imphal West, Manipur-795008. E-mail: firstname.lastname@example.org
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|Title Annotation:||Original Research Article|
|Author:||Singh, S. Robindro; Singh, S. Shyamchand; Luwang, T. Tozo|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Oct 20, 2016|
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