Re: Discussion: Laparoscopic bile duct exploration
I would like to thank Dr Ahmed for his complimentary letter and I am also very grateful to you for allowing me the ‘right of reply’.
A failure rate of 25% for endoscopic retrograde cholangiopancreatography (ERCP) would indeed be high but that figure refers to the number of patients in the series who had had ERCP before coming to laparoscopic bile duct exploration (LBDEx). This group is usually reported to have a higher rate of failure of laparoscopic clearance. There was no mention of failure rates of ERCP in the paper as it was simply a descriptive study of exploration via choledochotomy.
I agree that magnetic resonance cholangiopancreatography (MRCP) should be reserved for cases where there is suspicion of something other than just gallstones, e.g. coexistent cholangiocarcinoma. However, patients are referred to the Unit having already had tests (including failed ERCP); even so, only 7 of the 56 (13%) had had a preoperative MRCP. My personal preference is to operate, whether the patient is jaundiced or not, and image the bile duct using laparoscopic ultrasound avoiding either pre- or post-operative ERCP. Having said that, I have no problem with someone arranging a preoperative MRCP because I feel that the more information available before an operation the better.
While the size of the duct (taking into account the build of the patient) at the site of the proposed choledochotomy is very important, there are other factors that might influence the decision whether to go ahead, e.g. strength of the indication.
Dr Ahmed questions why I had used t-tubes but not antegrade stents. Only six patients (11%) had a t-tube and I wrote in the paper that they were only used when there was a real or perceived ampullary obstruction, and in that scenario, I have been reluctant to force anything through the papilla. This series is quite old now, having been written up in 2008, and in my subsequent 122 LBDExs (all types), no t-tubes (or antegrade stents) were used, although four patients had insertion of a biliary drain (transcystic 2, t-tube 2) during emergency reoperation.
T-tubes should be a last resort because of the inconvenience to the patient and their well-documented morbidity rates. However, I still believe they have a role after a difficult LBDEx where the surgeon is concerned, for whatever reason, about the risk of a significant leak from the bile duct closure and they remain an acceptable alternative to antegrade stenting.
In earlier days of laparoscopic surgery, planned post-operative ERCP had a definite role but in 2011, with the greatest respect, I do not agree with discontinuing an operation, leaving stones in the bile duct. In addition, there is a fundamental difference between LBDEx and ERCP in that the latter usually requires sphincterotomy for stone clearance. Placing an antegrade stent in preparation for ERCP may increase the ease and safety of cannulation but would not, in itself, have any bearing on stone clearance or the complication rate of sphincterotomy were it to be needed and its presence could impede the spontaneous passage of small stones through the papilla.
Michael D. Kelly, FRACS
Frenchay Hospital, Bristol, UK
