【正文】 s (Rhodes et al, Lancet, 1998) ERCP LCBDE CBD clearance 75%96% 90% Morbidity 13% 8% Mortality 1% 1% Pancreatitis 3% 1% (Tranter and Thompson, BJS, 2022) ? Patients who have a transcystic approach have a shorter hospital stay Options if laparoscopic transcystic exploration fails ? Ligate cystic duct, plete cholecystectomy and rely on postoperative ERCP ? Perform laparoscopic choledochotomy ? Laparotomy and open CBD exploration Options if laparoscopic choledochotomy fails ? Insert Ttube and extraction of stones after 6 weeks ? Postoperative ERCP ? Conversion to open CBD exploration Total choledocholithiasis 372 Transcystic bile duct clearance286 Failed Transcystic clearance86 Choledochotomy41 ERCP clearance45 Randomized trial in Brisbane (Nathanson et al, Ann Surg, 2022) ←Trial Randomization Randomized trial in Brisbane (Nathanson et al, Ann Surg, 2022) Operative Data (86 Failed Transcystic clearance) ERCP Choledochotomy P No. of stones (mean) Mean diameter of CBD (mm) Operative time: surgery (min) ERCPs / IOCs (min) Total (min) Bile duct closure Not applicable Primary 24 Antegrade stent 10 Ttube 7 Open conversions 1 1 No. having 2 ERCPs 11 0 Randomized trial in Brisbane (Nathanson et al, Ann Surg, 2022) Postoperative Outes (No Mortality) ERCP Choledochotomy P Bile leak 0 6 (2 settled, 3 ERCP, 1 reoperation) Pancreatitis Biochemical 4 3 Clinical (Glascow Score) 1 (2) 1 (4) Severe sepsis 1 1 Retained stone 2 (reoperation) 1 (ERCP) GI bleed 2 (transfusion) 0 Reoperation 3 3 Overall significant morbidity 6 (13%) 7 (17%) NS Hospital stay (mean, days) Recurrent or retained CBD stones ? Recurrent in 10% cases ? More mon in patients with primary duct stones, CBD 16mm and periampullary diverticula ? Retained stones found on Ttube cholangiogram best dealt with by ERCP ? Takes 6 weeks for tract to mature and allow percutaneous radiologically guided stone extraction or choledochoscopy successful in 95% and carries less risk of pancreatitis or haemorrhage Cholelithiasis Suspicion of CBD stones Selective perop cholangiogram No stones LC Routine perop cholangiogram Routine perop ERCP CBD stones CBD stones EST and duct clearance LC LCBDE OCBDE Postop ERCP Failure Failure Success Failure OCBDE LCBDE Failure Algorithm showing the available strategies for management of mon bile duct stones Shojaiefard A, et al. Various techniques for the surgical treatment of mon bile duct stones: a Meta review. Gastroenterology Research and Practice, 2022。 ③ cystic duct tube depresion CBD depression ? Controversy over Ttube, antegrade stents, cystic duct stents or no drainage ? If any doubts about free postoperative drainage of bile through ampulla, then depress ? Most likely to need depression if stone was impacted, extensive ampullary monipulation or cholangitis ? Subhepatic drainage essential Reasons to consider conversion to open choledochotomy ? Unsuccessful transcystic CBD exploration ? Unsuccessful laparoscopic CBD exploration ? Multiple CBD stones (10) ? Large CBD stones ? Intrahepatic or proximal duct stones ? Impacted stones ? Failed or unavailable ERCP Open choledochotomy ? Successful exploration involves an adequately sized choledochotomy to facilitate removal of stones and choledochoscopy ? Introduction of choledochoscopy (197080s) led to a decline in retained stones from 10% to % ? Choledochoscopy allows visualisation of several generations of upper ducts (when dilated) and the ampulla Ttube ? CBD depression ? Allows access to biliary tree for postoperative cholangiography and reexploration without the need for reoperation Ttube plications ? Fluid and electrolyte disturbances ? Bile leak around Ttube ? Bile leak after removal 1%19% ? Silicon coated latex tubes cause less fibrotic response than red rubber tubes, need to stay in longer (46weeks) to avoid biliary peritonitis on removal ? Advocated for plicated cases such as cholangitis, pancreatitis or difficult exploration ? In the absence of these factors primary closure has been shown to be as safe as Ttube drainage in several randomised trials (De Roover et al, Acta Chir Belg, 1989。 Rhodes et al, Lancet 1998) ? 12% patients managed without cholangiogram will present with a retained stone Transcystic exploration ? Standard dissection to identify cystic duct ? Cystic duct opened distal to a previously applied clip ? Milk stones from cystic duct ? Cholangiogram ? Assessment of stone and duct size ? Tiny stones or possible sphincter of oddi spasm try glucagon and flush with saline then repeat cholangiogram Transcystic exploration ? Nathanson basket fed into CBD (ensure tip of basket well back from tip to avoid duct perforation) ? Under image intensification tip positioned, basket opened and stone removed ? If stone impacted can dislodge with 4Fr fogarty catheter or perform choledochoscopy Techniques to improve transcystic clearance ? Careful dissection of cystic duct/CBD junction ? Avoidance of spiral valves when entering cystic duct ? Careful examination of cholangiogram ? Approach cystic duct from different or extra ports ? Dilation of cystic duct with a balloon ? Choledochoscopy via cystic duct ? Vary retraction on fundus ? Cystic duct closure clips or endoloops ? Subhepatic drainage Trans cystic exploration success ? Stones few in number ? Small in size (1cm) ? Situated in the mon