Transcystic Laparoscopic Common Bile Duct Exploration: When to Bail.

Abstract

Background: Transcystic laparoscopic common bile duct exploration (LCBDE) is a procedure considered in the management of common bile duct stones. In many ways it is superior to alternatives such as endoscopic retrograde cholangiopancreatography (ERCP); however, surgeons who have limited experience in CBDE are often reluctant to persist in difficult cases with concerns regarding increasing complication rates and waste of theater time. This study aims to provide an evidence-based approach to identify points to aid early abandonment ("bail").

Methods: Review of all LCBDE performed in a single center from September 2008 to September 2022 was performed. Statistical analysis was performed on success and failure groups, with relevant undesirable outcomes chosen for further analysis to identify factors to be used as a guide to bail.

Results: A total of 952 patients were identified for analysis. Females represented 63.8% (609) of the cohort. Success was reported in 89.2% (849) of procedures. Those in whom the cystic duct could not be cannulated with the choledochoscope, those that progressed to choledochotomy, those with a prolonged operative time, and those who had adverse outcomes were selected as undesired outcomes. Factors of age, higher ASA, preoperative ERCP, and those with preoperatively identified stones or larger stones at operation were associated with higher rates of an undesired outcome.

Conclusion: Older and more comorbid patients, those who underwent preoperative ERCP, and those with preoperatively or operatively identified large stones are factors that should prompt those surgeons who are developing their LCBDE experience to consider bailing early.