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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 3  |  Page : 1132-1136

Laparoscopic cystic duct exploration


Department of General Surgery, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Egypt

Date of Submission14-Dec-2016
Date of Acceptance05-Mar-2017
Date of Web Publication17-Oct-2019

Correspondence Address:
Ehab S. A. Mahmoud
Department of General Surgery, Faculty of Medicine, Menoufia University, Shebeen El-Kom
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_668_16

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  Abstract 

Objective
To evaluate the benefits of routine cystic duct exploration during laparoscopic cholecystectomy (LC).
Background
The era of LC has been established as it decreases postoperative pain, shortens the hospital stay, and returns the patient to full activity within 1 week. Cystic duct stones (CDS) especially in patients with multiple tiny gallbladder are implicated in postcholecystectomy pain, failure of insertion of transcystic intraoperative cholangiography catheter, and the subsequent development of common bile duct (CBD) stones.
Patients and methods
This was a prospective study that included 30 patients with chronic calcular cholecystitis with multiple tiny stones. The patients were operated at the Department of General Surgery, Menoufia University Hospital between December 2015 and August 2016. All patients were scheduled for LC with exploration of cystic duct; intraoperative cholangiogram was done only for five cases.
Results
CDS were detected in nine cases in different patterns (multiple stones, single stone, gravels). CDS were detected more in patients with elevated liver functions including alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, γ-glutamyl transferase. CDS were detected more in patients with dilated cystic duct. CBD stones were found in one case detected by transcystic intraoperative cholangiography; endoscopic retrograde cholangiopancreaticography was done in the same session. No postoperative complications were found regarding bile leak, obstructive jaundice, and postcholecystectomy pain.
Conclusion
Cystic duct exploration as a routine step in LC especially in patients with multiple gallbladder stones is a safe and easy to perform procedure that may help in protection against complications after cholecystectomy including postcholecystectomy pain, missed CBD stones, and pancreatitis with no increase in the time of procedure or risk on patients.

Keywords: common bile duct, cystic duct stones, laparoscopic cholecystectomy, obstructive jaundice, postcholecystectomy pain


How to cite this article:
Soltan HM, Ammar MS, El Balshy MA, Mahmoud ES. Laparoscopic cystic duct exploration. Menoufia Med J 2019;32:1132-6

How to cite this URL:
Soltan HM, Ammar MS, El Balshy MA, Mahmoud ES. Laparoscopic cystic duct exploration. Menoufia Med J [serial online] 2019 [cited 2019 Dec 7];32:1132-6. Available from: http://www.mmj.eg.net/text.asp?2019/32/3/1132/268829




  Introduction Top


The era of laparoscopic cholecystectomy (LC) has been established as it decreases postoperative pain, shortens the hospital stay from 1 week to less than 24 h, and returns the patient to full activity within 1 week (compared with 1 month after open cholecystectomy) [1].

LC also provides improved cosmesis and improved patient satisfaction as compared with open cholecystectomy [2].

Cystic duct stones (CDS) especially in patients with multiple tiny gall bladder are implicated in postcholecystectomy pain [3]. Failure of insertion of on-table cholangiogram catheter causes development of common bile duct (CBD) stones and obstructive jaundice [4]. Mirizzi syndrome is another possible complication where large stones impact the cystic duct, causing external compression and possibly erosion of the CBD [5].

Postcholecystectomy syndrome is a common manifestation in patients with cholecystectomy. The patients exhibit a heterogeneous group of symptoms, such as upper abdominal pain, vomiting, gastrointestinal disorders, jaundice, and dyspepsia. Choledocholithiasis is the cause of these symptoms [3].

Obstructive jaundice is another serious postoperative complication of missed stones after cholecystectomy either in cystic duct or CBD [6].

Another complication which may be fatal from missed CDS especially small stones which can be mobilized after LC causing obstruction of pancreatic duct with bile reflux causing activation of pancreatic enzymes with pancreatic autodigestion with elevation of amylase and lipase, that may be associated with severe systemic inflammation which may end in multiorgan system failure [5].

Some centers prefer to do routine intraoperative cholangiogram for all patients during LC even with normal parameters. In this study routine cystic duct exploration was done during LC for all patients; transcystic intraoperative cholangiography (TIOC) was done only for five cases.

There are many randomized trials that show the frequency of CDS during LC and the role of cystic duct exploration as a routine procedure during LC [7].


  Patients and Methods Top


This was a prospective study that included 30 patients with chronic calcular cholecystitis with multiple tiny stones; the patients were operated at the Department of General Surgery, Menoufia University Hospital between December 2015 and August 2016.

All patients were scheduled for LC with exploration of cystic duct and written informed consent was obtained from all patients.

The inclusion criteria were patients with multiple tiny gall bladder stones visible on abdominal ultrasound; patients with normal CBD average diameter with no impacted stones or gravels; patients with normal liver functions including alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), γ-glutamyl transferase (GGT), total bilirubin (TB), and direct bilirubin (DB); patients with minimally deranged liver functions including ALT, AST, ALP, and GGT; and patients with normal coagulation profile.

The exclusion criteria were patients with single or multiple large gall bladder stones, patients with obstructive jaundice, patients unfit for laparoscopic surgery, patients with past history of major upper abdominal operations and cirrhotic patients.

All cases included in this study were subjected to clinical evaluation: history taking, personal, family, past history of medical diseases, and history of surgical operations. Clinical examination: general and local examination. Investigations: complete blood count, random blood sugar, serum urea, serum creatinine, bleeding profile, liver functions including ALT, AST, ALP, GGT, TB, DB ECG, abdominopelvic ultrasound, and magnetic resonance cholangiopancreatography in selected cases with doubt of CBD stones.

In this study before transection of cystic duct an endo-clip was inserted at the junction of the gallbladder-cystic duct. An anterolateral incision was made in the cystic duct and Maryland dissector was used to milk the cystic duct toward the gallbladder before transection. Any encountered CDS were retrieved and documented [Figure 1]. The same Maryland was used for all cases, the length of the Maryland blade was measured (10 mm); it was used as a measuring tool for cystic duct diameter. The average diameter of the cystic duct was 1–3 mm. Dilated cystic duct was ligated by megaclips and they were sufficient.
Figure 1: Cystic duct stones.

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Intraoperative cholangiogram was done for five cases with multiple CDS; ureteric catheter was inserted through the small incision of the cystic duct, then the catheter has been advanced through the specialized cholangiogram clamp into the cystic duct. The clamp was inserted through the 5 mm trocar in the right midclavicular line [Figure 2].
Figure 2: Transcystic intraoperative cholangiography.

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The contrast dye is gently injected to monitor opalescence of the distal bile duct and to identify CBD stones. CBD stones were discovered in one case; endoscopic retrograde cholangiopancreaticography (ERCP) was done in the same session.

All patients had a follow-up visit 10 days postoperatively. Follow-up investigation included ALP, TB, and DB.

Statistical analysis

Statistical presentation and analysis of this study was conducted using the Statistical Package for the Social Sciences (version 20; SPSS Inc., Chicago, Illinois, USA) on an IBM compatible computer.

Two types of statistics were determined: descriptive statistics and analytic statistics.

Descriptive statistics included percentage, mean value (X 0−), and SD.

Mean value (X−) is the sum of all observations divided by the number of observations:

Where å is the sum and n is the number of observations.

SD measures the degree of scatter of individual values around their mean:

Analysis of variance was performed for comparison among different times in the same group for quantitative data, using the computer program SPSS for Windows.

The χ2-test was based on the hypothesis that the row and column variables are independent, without indicating strength or direction of the relationship. Pearson's χ2- and likelihood ratio χ2 were determined. Fisher's exact test and Yates' corrected χ2-test were used for 2 × 2 tables.

The χ2-test was used for comparison between two groups as regards qualitative data:

Where is the summation and O is the observed value.

All these tests were used as tests of significance at a P value of less than 0.05.


  Results Top


The demographic characteristics among the studied sample of patients (n = 30) demonstrated that there was increased percentage of women (73.3%, 22) than men (26.7%, 8) [Table 1].
Table 1: Demographic characteristics among the studied sample of patients (n=30) regarding sex

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The demographic characteristics among the studied sample of patients (n = 30) demonstrated that there ages ranged between 25 and 75 years with mean ± SD of (45.57 ± 16.722) [Table 2].
Table 2: Demographic characteristics among the studied sample of patients (n=30) regarding age

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Laboratory investigations were done routinely for all patients including ALT, AST, ALP, GGT; 56.7% (17) of patients had normal liver functions; 43.3% (13) of patients had minimally elevated liver functions concerning ALT, AST, ALP, GGT [Table 3].
Table 3: Liver functions including AIT, aspartate aminotransferase, alkaline phosphatase, γ-glutamyl transferase (n=30)

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There is a statistically significant difference between normal and deranged liver functions ALT, AST, ALP, GGT patients regarding detected CDS as only 6.00% (1) of normal patients had CDS compared with 61.5% (8) of patients with deranged liver functions who had CDS (P = 0.001) [Table 4].
Table 4: Relation between liver functions and cystic duct stones (n=30)

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Cystic duct exploration was done for all patients; CDS were detected in 30% (9) of patients [Table 5].
Table 5: Cystic duct stones detected (n=30)

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Cystic duct exploration showed CDS in different patterns, single stone in 22.5% (2), multiple stones in 55% (2), gravels in 22.5% (2) [Table 6].
Table 6: Different patterns of cystic duct stones (n=30)

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The percentage of abnormally dilated cystic duct noted during LC was 20% (6), with about 80% (24) of average diameter [Table 7].
Table 7: Dilated cystic duct (n=30)

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There is a statistically significant difference between normal and dilated cystic duct patients regarding detected CDS as only 16.7% (4) of normal cystic duct patients had CDS compared with 83.4% (5) of dilated cystic duct who had CDS (P = 0.007) [Table 8].
Table 8: Relation between cystic duct stones and cystic duct dilatation (n=30)

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  Discussion Top


Dave et al. [1] published that: a prospective study from St James University Hospital found CDS shown on On-table cholangiogram (OTC) during LC at an incidence of 20%.

Mahmud et al. [4] stated that: previous retrospective studies about CDS found incidences of 12.3 and 14.7%, respectively.

This study demonstrated CDS in 30% (9) of cases. This figure is based on operative milking of the cystic duct, the true incidence may be different if an TIOC policy is applied to all cases.

Pain after cholecystectomy usually presents with a wide range of possible causes. Residual CDS are thought to be accountable in 17–25% of cases. This group of patients has a theoretically preventable condition if attention is paid at surgery to detect all CDS [8].

In this study postcholecystectomy syndrome had not been detected as preoperatively routine investigations were done, US revealed no CDS [Table 3], liver functions including ALT, AST, GGT, ALP were normal or minimally deranged [Table 6]. Intraoperative cystic duct was dissected carefully and explored in all cases, short cystic stump was left, no gallbladder remnants were left.

Amir et al. [7] found that of the 64 patients with CDS, 47 had deranged LFTs at some stage before surgery. LFTs were also deranged in 152 of the 266 patients without CDS. Using a χ2-test for these data, a statistically positive association between the presence of CDS and abnormal liver functions was noted (P = 0.03). The sensitivity of LFTs to detect CDS was 73%, and their specificity was 43%.

This agrees with our study that there is a statistically significant difference between normal and deranged liver functions ALT, AST, ALP, GGT in patients regarding detected CDS as only 6.00% of normal patients had CDS compared with 61.5% of patients with deranged liver functions who had CDS (P = 0.001).

Dave et al. [1] published that: 248 LC with TIOC had been recorded from 4 July 2010. The presence of CDS was not significantly associated with raised liver function tests nor with preoperative diagnoses of cholecystitis, pancreatitis, jaundice, or cholangitis.

This disagrees with our study as CDS were found more with patients with elevated liver functions.

Castelain et al. [9] published that they thought to measure cystic duct diameter in patients without biliary calculi and in those with cholelithiasis or choledocholithiasis. Using ERCP, they visualized the cystic duct in 168 patients referred to their unit. These patients were distributed into three groups based on findings at ERCP: group I (N = 57), no calculi in the gallbladder or CBD; group II (N = 27), stones found in the gallbladder but absent from the CBD; and group III (N = 34), stones present in the CBD with or without gallbladder stones. The diameter of the cystic duct was measured at its widest and narrowest dimensions. The largest diameter measured was greater in group III than in groups I and II. Maximal cystic duct diameter shows a progressive increase at each level of disease. This increase in cystic duct size may facilitate the migration of gallstone fragments after lithotripsy and facilitate the instrumentation of the cystic duct during ERCP and LC.

This agrees with this study that showed that there is a statistically significant difference between normal and dilated cystic duct patients regarding detected CDS as only 16.7% of normal cystic duct patients had CDS compared with 83.4% of dilated cystic duct patients who had CDS (P = 0.007).

Sezeur and Akel [10] published that: CBD stones are known to occur more frequently in association with CDS. The reported rates in the literature varied from 23.8 to 5.7% in the absence of CDS.

In this study, CBD stones were detected by TIOC in one case of five cases with multiple CDS; ERCP was done at the same session.

Sharma et al. [11] published that: to assess the value of preoperative indicators of CBD stones, 167 patients undergoing cholecystectomy were randomized to receive either routine (R) or selective (S) TIOC. In all, 81/84 patients in the R group and 22/78 in the S group had TIOC (P < 0.0001). In the R group, 11/81 were positive (one false-positive) and in the S group 7/22 were positive (P < 0.05) CBD stones. The study has demonstrated that selective use of TIOC can be safely used in cholecystectomies.

This agrees with our study as routine cystic duct exploration with selective TIOC policy can be safely used in LC.


  Conclusion Top


Cystic duct exploration as a routine step in LC especially in patients with multiple gallbladder stones is a safe and easy to perform procedure that may help in protection against complications after cholecystectomy including postcholecystectomy pain, missed CBD stones, and pancreatitis with no increase in the time of procedure or risk on patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dave R, Yeomans N, Cockbain A, Toogood G. The incidence and management of cystic duct stones, the intra-operative cholangiogram is more than just a diagnostic tool. Liverpool, UK: International Surgical Congress; 2012.  Back to cited text no. 1
    
2.
Tantia O, Jain M, Khanna S, Sen B. Post-cholecystectomy syndrome: role of cystic duct stump and re-intervention by laparoscopic surgery J Minim Access Surg 2008; 4:71–75.  Back to cited text no. 2
    
3.
Demetriades H, Pramateftakis MG, Kanellos I, Angelopoulos S, Mantzoros I, Betsis D. Retained gallbladder remnant after laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech A 2008; 18:276–279.  Back to cited text no. 3
    
4.
Mahmud S, Hamza Y, Nassar AH. The significance of cystic duct stones encountered during laparoscopic cholecystectomy. Surg Endosc 2001; 15:460–462.  Back to cited text no. 4
    
5.
Erben Y, Benavente-Chenhalls LA, Donohue JM, Que FG, Kendrick ML, Reid-Lombardo KM, et al. Diagnosis and treatment of Mirizzi syndrome: 23-year Mayo Clinic experience. J Am Coll Surg 2013; 213:114–121.  Back to cited text no. 5
    
6.
Jung CW, Min BW, Song TJ, Son GS, Lee HS, Kim SJ, et al. Mirizzi syndrome in an anomalous cystic duct: a case report. World J Gastroenterol 2007; 13:5527–5529.  Back to cited text no. 6
    
7.
Amir K, Richards T, Jayamanne H, Sallami Z, Rasheed A, Lazim T. Instrumental detection of cystic duct stones during laparoscopic cholecystectomy. Hepatobiliary Pancreat Dis Int 2014; 13:215–218.  Back to cited text no. 7
    
8.
Köckerling F, Schneider C, Reymond MA, Hohenberger W. Extraction of cystic duct occlusion calculus in laparoscopic cholecystectomy. Zentralbl Chir 1997; 122:295–298.  Back to cited text no. 8
    
9.
Castelain M, Grimaldi C, Harris AG, Caroli-Bosc FX, Hastier P, Dumas R, et al. Relationship between cystic duct diameter and the presence of cholelithiasis. Dig Dis Sci 1993; 38:2220–2224.  Back to cited text no. 9
    
10.
Sezeur A, Akel K. Cystic duct remnant calculi after cholecystectomy. J Visc Surg 2011; 148:e287–e290.  Back to cited text no. 10
    
11.
Sharma AK, Cherry R, Fielding JW. A randomised trial of selective or routine on-table cholangiography. Ann R Coll Surg Engl 1993; 75:245–248.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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