Assess the early result of laparoscopic choledochotomy to treat biliary tract stones – Su Quoc Khoi

Journal of military pharmaco-medicine n o 9-2018 153 ASSESS THE EARLY RESULT OF LAPAROSCOPIC CHOLEDOCHOTOMY TO TREAT BILIARY TRACT STONES Su Quoc Khoi1; Nguyen Van Xuyen2; Dang Viet Dung2 SUMMARY Background: Biliary tract stones is a common disease. The treatment still faces with many difficulties and the residual rate is still high. Laparoscopic surgery to treat biliary tract stones has many advantages such as no much pain and less postoperative hospital stay. Therefore, it is indicated more and more in treating biliary tract stones. Objectives: To assess the early results of laparoscopic choledochotomy in treatment of biliary tract stones. Subjects and methods: A prospective study includes totally 103 patients. Results: Laparoscopic choledochotomy in treatment of biliary tract stones was performed on 103 cases with female/male ratio of 35/68. 64 patients had never undergone bile duct surgery before, 39 cases of biliary tract were reoperated, success rate: 97.1%, conversion to open: 2.9%, postoperative hospital stay: 10.5 ± 2.7 days, the proportion of the first time stone clearance: 83.0%, the rate of remaining stone: 17.0%. Conclusions: Laparoscopic choledochotomy in treatment of biliary tract stones has high successful rate and high proportion of stone clearance, low rate of accidence, no death. * Keywords: Biliary tract stones; Laparoscopy; Choledochotomy. INTRODUCTION Biliary stones are common diseases in Vietnam as well as in the world. Choledocholithis in our country is usually primary stones, large numbers, large size, many positions. There are a number of different methods to treat biliary tract stones, but surgery still plays an important role in eliminating all stones, reducing recurrence, early recovery... Laparoscopic surgery has the advantage of anesthesia, painlessness, early recovery. Laparoscopic choledochotomy to remove common bile duct stones has been applied at Kiengiang General Hospital since 2014, but not yet fully evaluated. Therefore, we conducted a study to: Evaluate the results of laparoscopic choledochotomy to treat biliary tract stones. SUBJECTS AND METHODS 1. Subjects. There are a total of 103 patients including 35 males, 68 females (aged 24 - 89 years) with biliary tract stones, were treated by laparoscopic choledochotomy at General Surgery Department, Kiengiang General Hospital from 2014 to 2017. 1. Kiengiang General Hospital 2. 103 Military Hospital Corresponding author: Su Quoc Khoi (drkhoi78@gmail.com) Date received: 11/10/2018 Date accepted: 20/11/2018 Journal of military pharmaco-medicine n o 9-2018 154 2. Methods. + Study design: Prospective study. + Surgery technique. * Criteria for selection: Patients with biliary tract stones including patients have never undergone bile duct surgery before and biliary tract reoperation, endoscopic retrograde cholangiopancreatography failed, with cholelithiasis and/or hepatolithiasis were diagnosed with computerized tomography and/or endoscopic retrograde cholangiopancreatography. - Patient supine, surgeon standing on the right, assistants standing on the left of the patient. - Place 4 trocars: 2 trocars 5 mm, 2 trocars 10 mm. - Air insufflation ≤ 12 mmHg. - Investigate the abdominal cavity and find the common bile duct. - Choledochotomy with hooks or scissors. - Removing stones: using Randall port to remove the stones. - Cholangioscopy: If you have residual stones, removal stones by Randall, dormia, forgaty, hydraulic electric lithotripsy. If it is not possible to remove all stones, let the active stones and lithotripsy via the Kehr tunnel. - Place the Kehr tube. - Cholecystectomy when indicated. - Evaluation of results: + Intraoperative accidents: bleeding, organ injury... + Postoperative complications: Bleeding, bile fistula, peritonitis... + Surgical results: Operative time, hospital stay time, rate of conversion to open surgery, rate of stones clearance, stone residual rate, mortality rate, recurrence rate. - Data processing: SPSS 20.0, p < 0.05 was considered statistically significant. RESULTS AND DISCUSSION 1. General features. - Male/female ratio: 35/68, mean age: 56.2 ± 14.9 years (24 - 89). First surgery: 64 cases. Reoperation: 39 cases. Among them, 29 cases were once pre-choledochotomy in history. Location of stones: Extrahepatic biliary tract stones: 48/103 patients (46.6%); intrahepatic and extrahepatic biliary tract stones: 55/103 patients (53.4%); 43 patients (41.7%) had cholecystolithiasis. Biliary tract stones disease occurs in both men and women. Women are more prevalent than men. According to domestic authors, percentages of patients by gender in male and female were 30.8 - 43.9% and 56.1 - 69.2%, respectively, the ratio ranges 1:2 to 2:3. Biliary tract stones disease can be found at many different ages. Studies in our country have also been encountered at various ages and suggest that the indication for old people is safe [2, 3, 4, 6]. We performed choledochotomy for treatment of biliary tract stones for the first surgery group and reoperation, intrahepatic and extrahepatic biliary tract stones. Journal of military pharmaco-medicine n o 9-2018 155 2. Surgical results. Success rate: 97.1%. Evaluation is successful when laparoscopic surgery is performed and removing stones. Our failure cases were caused by intraoperative accidents, adhesion which led to convert to open surgery. We did not have any cases of trapped stones, difficult stones to remove, can not lithotripsy as the author Nguyen Hoang Bac. In this study, we had a lot of reoperation cases, so our success rate was lower. Our results had a higher success rate than Nguyen Khac Duc’s findings with a success rate of 86.4%. Berthou performed 304 cases, a success rate of 97% [2, 3, 7]. Conversion to open surgery: 3 cases. Causes of conversion due to intraoperation accidents are uncontrolable bleeding and duodenal perforation, so we can not carry out laparoscopic surgery. All of converted cases were biliary tract stone reoperation. Tran Manh Hung, Nguyen Khac Duc: conversion to open is not a failure, but it is only a change of surgical method to be safer [3, 4]. Table 1: Conversion rate. Author n Conversion rate Nguyen Hoang Bac 172 2.3% Nguyen Khac Duc 148 13.6% Petelin 57 1.8% Berthou 304 2% Our study 103 2.9% Average operative time for 100 successful cases: 139.3 ± 50.0 minutes (55 - 275). Group of biliary tract stone reoperation, hepatolithiasis, intraoperative lithotripsy has a longer operative time than the first surgery group, no hepatolithiasis and intraoperative lithotripsy. The difference was statistically significant. Our operation time was longer than that in Tran Manh Hung’s study: 68 minutes (45 - 120), Nguyen Hoang Bac: 117 minutes (35 - 270), Berthou 124 minutes (49 - 360) but shorter than Nguyen Khac Duc’s: 150 minutes (80 - 320) and Lee’s: 187 ± 67.0 minutes. Our surgery time was longer than that in some other authors’study due to: the rate of biliary tract stone reoperation was 36% in 100 successful cases. Tran Manh Hung only performed surgery for the first time, Nguyen Hoang Bac 7/172 cases, Nguyen Khac Duc 7/148 cases; our cholangioscopy rate was 100%. Nguyen Hoang Bac (25.5%), and Nguyen Khac Duc had no case [2, 3, 4, 7]. - Remaining stones: The rate of our stone clearance after operation was 83% and 17% remaing stones: Cholangioscopy was performed on 12 cases of remaning stones but not continue to remove stones or lithotripsy. 5 real residual stones were found during postoperative and follow-up time. We removed the stones in the operation as much as possible. Therefore, the number of stones clearance is higher than that in Nguyen Hoang Bac’s study. If we try to remove stone for the first surgery, it will increase the rate of stone clearance and reduce number of lithotripsy after surgery. Nguyen Hoang Bac had an average of 2.28 times (1 - 6 times) of lithotripsy [2]. Journal of military pharmaco-medicine n o 9-2018 156 Intraoperative accidents: 04/103 cases, 2 cases of bleeding when we had done choledoctotomy, bleeding is difficult to control and 01 case of duodenal perforation was converted to open surgery to manage; 01 case of duodenal laceration was sutured by laparoscopic surgery. These cases occurred in patients of biliary tract stones reoperation. Postoperation is stable. Some studies in the country showed that the rate of bleeding range 1 - 2.4%, gastrointestinal perforation was 0.8% [2, 3, 4]. Death: In our study, no deaths occurred during postoperative period and one month after surgery. Our results were similar to other authors’ findings in the country: Nguyen Hoang Bac, Bui Tuan Anh [1, 2]. - Average hospital stay time: 10.5 ± 2.7 days (6 - 22). Average hospital stay for the first surgery and reoperative group was not significantly different (p = 0.6). Patients > 70 years of age had longer hospital stay time than those < 70 years but no statistically significant difference. Table 2: Hospital stay time. Authors’ studies n Average hospital stay time Bui Tuan Anh 56 8.78 Nguyen Khac Duc 128 8.9 ± 3.3 Tran Manh Hung 104 5.65 ± 1.6 Ours 100 10.5 ± 2.7 The average hospital stay time in Nguyen Khac Duc’s study: 8.9 ± 3.3 days. Tran Manh Hung, hospital stay time is not fully dependent on the recovery ability of patients but also depends on many other factors. Decker: The same surgical procedure, but hospital stay time is different because in addition to recovery factor, there are others such as treatment facilities, socio-economic conditions [3, 8, 9]. CONCLUSION Laparoscopic choledochotomy to remove biliary tract stones is a method that has a high success rate for cases of first choledocholithiasis and biliary tract stones reoperation. Laparoscopic surgery is an effective treatment for both cases of first choledocholithiasis and biliary tract stones reoperation with rate of stone clearance 83%, stones remaining rate of 17%, the incidence of low accidents, no deaths. REFERRENCE 1. Bui Tuan Anh, Nguyen Quang Nam. Preliminary assessment of efficiency and safety of treatment laparoscopic surgery of biliary stones with previous surgery. Clinical Medicine Journal. 2016, 33, pp.24-28. 2. Nguyen Hoang Bac. Indication of laparoscopic surgery in treating biliary tract stones. PhD Thesis in Medicine. University of Medicine and Pharmacy. Hochiminh City. 2007. 3. Nguyen Khac Duc. Applied research of laparoscopic surgery to treat extrahepatic tract stones. PhD Thesis in Medicine. Ha Noi Medicine University. 2010. 4. Nguyen Khac Duc, Tran Hue Son. Indications of laparoscopic common bile duct remove stones at Vietduc Hospital from 2000 to 2012. Viet Nam Journal of Endolaparoscopic Surgery. 2015, 5, pp.28-33. Journal of military pharmaco-medicine n o 9-2018 157 5. Tran Manh Hung. Applied research of laparoscopic choledocholithotomy without T-tube drainage. PhD Thesis in Medicine. Military Medical University. 2012. 6. Do Kim Son, Tran Gia Khanh, Doan Thanh Tung et al. Reasearch and surgical management of biliary stone diseases at Vietduc Hospital (5,773 cases from 1976 to 1998). Surgery. 2000, 2, pp.18-23. 7. Berthou J.C, Dron B, Charbonneau B et al. Evaluation of laparoscopic treatment of common bile duct stones in a prospective series of 505 patients: indications and results. Surg Endosc. 2007, 21 (11), pp.1970-1974. 8. Decker G, Borie F, Millat B et al. One hundred laparoscopic choledochotomies with primary closure of the common bile duct. Surg Endosc. 2003, 17 (1), pp.12-18.