A proposed difficulty grading system for laparoscopic bile duct exploration: benefits to clinical practice, training and research.

BACKGROUND: A gap remains between the mounting evidence for single session management of bile duct stones and the adoption of this approach. Laparoscopic bile duct exploration (LBDE) is limited by the scarcity of training opportunities and adequate equipment and by the perception that the technique requires a high skill-set. The aim of this study was to create a new classification of difficulty based on operative characteristics and to stratify postoperative outcomes of easy vs. difficult LBDE irrespective of the surgeon's experience. METHODS: A cohort of 1335 LBDEs was classified according to the location, number and size of ductal stones, the retrieval technique, utilisation of choledochoscopy and specific biliary pathologies encountered. A combination of features indicated easy (Grades I and II A & B) or difficult (Grades III A and B, IV and V) transcystic or transcholedochal explorations. RESULTS: 78.3% of patients with acute cholecystitis or pancreatitis, 37% with jaundice and 46% with cholangitis had easy explorations. Difficult explorations were more likely to present as emergencies, with obstructive jaundice, previous sphincterotomy and dilated bile ducts on ultrasound scans. 77.7% of easy explorations were transcystic and 62.3% of difficult explorations transductal. Choledochoscopy was utilised in 23.4% of easy vs. 98% of difficult explorations. The use of biliary drains, open conversions, median operative time, biliary-related complications, hospital stay, readmissions, and retained stones increased with the difficulty grade. Grades I and II patients had 2 or more hospital episodes in 26.5% vs. 41.2% for grades III to V. There were 2 deaths in difficulty Grade V and one in Grade IIB. CONCLUSION: Difficulty grading of LBDE is useful in predicting outcomes and facilitating comparison between studies. It ensures fair structuring and assessment of training and progress of the learning curve. LBDEs were easy in 72% with 77% completed transcystically. This may encourage more units to adopt this approach.

Utilization of Laparoscopic Choledochoscopy During Bile Duct Exploration and Evaluation of the Wiper Blade Maneuver for Transcystic Intrahepatic Access.

OBJECTIVE: This study aims to examine the indications, techniques, and outcomes of choledochoscopy during laparoscopic bile duct exploration and evaluate the results of the wiper blade maneuver (WBM) for transcystic intrahepatic choledochoscopy. SUMMARY OF BACKGROUND DATA: Choledochoscopy has traditionally been integral to bile duct explorations. However, laparoscopic era studies have reported wide variations in choledochoscopy availability and use, particularly with the increasing role of transcystic exploration. METHODS: The indications, techniques, and operative and postoperative data on choledochoscopy collected prospectively during transcystic and choledo- chotomy explorations were analyzed. The success rates of the WBM were evaluated for the 3 mm and 5 mm choledochoscopes. RESULTS: Of 935 choledochoscopies, 4 were performed during laparoscopic cholecystectomies and 931 during 1320 bile duct explorations (70.5%); 486 transcystic choledochoscopies (52%) and 445 through choledochotomies (48%). Transcystic choledochoscopy was utilized more often than blind exploration (55.7%% vs 44.3%) in patients with emergency admissions, jaundice, dilated bile ducts on preoperative imaging, wide cystic ducts, and large, numerous or impacted bile duct stones. Intrahepatic choledochoscopy was successful in 70% using the 3 mm scope and 81% with the 5 mm scope. Choledochoscopy was necessary in all 124 explorations for impacted stones. Twenty retained stones (2.1%) were encountered but no choledochoscopy related complications. CONCLUSIONS: Choledochoscopy should always be performed during a chol- edochotomy, particularly with multiple and intrahepatic stones, reducing the incidence of retained stones. Transcystic choledochoscopy was utilized in over 50% of explorations, increasing their rate of success. When attempted, the transcystic WBM achieves intrahepatic access in 70%-80%. It should be part of the training curriculum.

Conventional Surgical Management of Bile Duct Stones: A Service Model and Outcomes of 1318 Laparoscopic Explorations.

OBJECTIVE: The primary aim of this study was to describe the service model of one-session management, with a limited role for preoperative endoscopic clearance. The secondary aim was to review the outcomes and long term follow up in comparison to available studies on LCBDE. BACKGROUND: The laparoscopic era brought about a decline in the conventional surgical management of common bile duct stones. Preoperative endoscopic removal became the primary method of managing choledocholithiasis. Although LCBDE deals with gallstones and ductal stones in onw session, the limited availability of such an advanced procedure perpetuated the reliance on the endoscopic approach. METHODS: Prospective data was entered into a single surgeon's database containing 5739 laparoscopic cholecystectomy over 28 years and analyzed. RESULTS: One thousand eighteen consecutive LCBDE were included (23% of the series). Intraoperative cholangiography was performed in 1292 (98.0%). The median age was 60 years, male to female ratio 1:2 and 75% were emergency admissions. Most patients (43.4%) presented with jaundice. 66% had transcystic explorations and one third through a choledochotomy with 2.1% retained stones, 1.2% conversion, 18.7% morbidity, and 0.2% mortality. Postoperative ERCPs were needed in 3.1%. Recurrent stones occurred in 3%. CONCLUSIONS: One stage LCBDE is a safe and cost-effective treatment where the expertise and equipment are available. Endoscopic treatment has a role for specific indications but remains the first-line treatment in most units. This study demonstrates that establishing specialist services through training and logistic support can optimize the outcomes of managing common bile duct stones.

Gall Bladder Empyema: Early Cholecystectomy during the Index Admission Improves Outcomes.

OBJECTIVES: We aim to evaluate our policy of index admission management of gall bladder empyema and the effect of the timing of surgery on the outcomes. METHODS: We analyzed a series of 5400 laparoscopic cholecystectomies. Data were collected prospectively over 26 y. Patients were divided into two groups: group 1, intervention within 72 h, and group 2, intervention after 72 h of admission. We had a policy of intention to treat during the index admission, but delays sometimes occurred because of late referral, a need to optimize patients, availability of theater time, or the biliary surgeon being on leave. The groups were then compared with regard to the duration of surgery, the difficulty grading, complications, hospital stay, and conversion rate. RESULTS: A total of 372 patients were included; 160 (43%) operated on within 72 h (group 1) and 212 (57%) after 72 h (group 2). There was no statistically significant difference between the two groups with regard to the operation time, conversion rate, and complications rate. The difference in total hospital stay was, however, statistically significant. CONCLUSION: Surgical management of empyema should be offered as soon as possible after admission as with any acute cholecystitis. Surgery carried out after 72 h of admission is only associated with longer hospital stay but no statistically significant differences in other outcome parameters. In the presence of specialist expertise, fitness for surgery should be the determining factor of whether or not to offer surgery to these patients, regardless of the interval since their admission.

Predicting the difficult laparoscopic cholecystectomy: development and validation of a pre-operative risk score using an objective operative difficulty grading system.

BACKGROUND: The prediction of a difficult cholecystectomy has traditionally been based on certain pre-operative clinical and imaging factors. Most of the previous literature reported small patient cohorts and have not used an objective measure of operative difficulty. The aim of this study was to develop a pre-operative score to predict difficult cholecystectomy, as defined by a validated intra-operative difficulty grading scale. METHOD: Two cohorts from prospectively maintained databases of patients who underwent laparoscopic cholecystectomy were analysed: the CholeS Study (8755 patients) and a single surgeon series (4089 patients). Factors potentially predictive of difficulty were correlated to the Nassar intra-operative difficulty scale. A multivariable binary logistic regression analysis was then used to identify factors that were independently associated with difficult laparoscopic cholecystectomy, defined as operative difficulty grades 3 to 5. The resulting model was then converted to a risk score, and validated on both internal and external datasets. RESULT: Increasing age and ASA classification, male gender, diagnosis of CBD stone or cholecystitis, thick-walled gallbladders, CBD dilation, use of pre-operative ERCP and non-elective operations were found to be significant independent predictors of difficult cases. A risk score based on these factors returned an area under the ROC curve of 0.789 (95% CI 0.773-0.806, p < 0.001) on external validation, with 11.0% versus 80.0% of patients classified as low versus high risk having difficult surgeries. CONCLUSION: We have developed and validated a pre-operative scoring system that uses easily available pre-operative variables to predict difficult laparoscopic cholecystectomies. This scoring system should assist in patient selection for day case surgery, optimising pre-operative surgical planning (e.g. allocation of the procedure to a suitably trained surgeon) and counselling patients during the consent process. The score could also be used to risk adjust outcomes in future research.

Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy.

BACKGROUND: A reliable system for grading operative difficulty of laparoscopic cholecystectomy would standardise description of findings and reporting of outcomes. The aim of this study was to validate a difficulty grading system (Nassar scale), testing its applicability and consistency in two large prospective datasets. METHODS: Patient and disease-related variables and 30-day outcomes were identified in two prospective cholecystectomy databases: the multi-centre prospective cohort of 8820 patients from the recent CholeS Study and the single-surgeon series containing 4089 patients. Operative data and patient outcomes were correlated with Nassar operative difficultly scale, using Kendall's tau for dichotomous variables, or Jonckheere-Terpstra tests for continuous variables. A ROC curve analysis was performed, to quantify the predictive accuracy of the scale for each outcome, with continuous outcomes dichotomised, prior to analysis. RESULTS: A higher operative difficulty grade was consistently associated with worse outcomes for the patients in both the reference and CholeS cohorts. The median length of stay increased from 0 to 4 days, and the 30-day complication rate from 7.6 to 24.4% as the difficulty grade increased from 1 to 4/5 (both p < 0.001). In the CholeS cohort, a higher difficulty grade was found to be most strongly associated with conversion to open and 30-day mortality (AUROC = 0.903, 0.822, respectively). On multivariable analysis, the Nassar operative difficultly scale was found to be a significant independent predictor of operative duration, conversion to open surgery, 30-day complications and 30-day reintervention (all p < 0.001). CONCLUSION: We have shown that an operative difficulty scale can standardise the description of operative findings by multiple grades of surgeons to facilitate audit, training assessment and research. It provides a tool for reporting operative findings, disease severity and technical difficulty and can be utilised in future research to reliably compare outcomes according to case mix and intra-operative difficulty.

Correction to: Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy.

The list of the CholeS management group, Collaborators and Data Validators were omitted from the Acknowledgments.