CBDEEpisode
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[00:00:00] Welcome back to Behind the Knife the Surgery podcast, where we bring you the cutting edge of surgical science and technique. In this episode, our MIS team will take on common bile duct explorations, reviewing key papers that have shaped our approach to Chodo ssis from our first forays in laparoscopic exploration to new and bonafide.

Robotic options. I'm Shana Eckhouse, associate Professor of Surgery, medical Director of Iatric Surgery and Vice Chair of Clinical Operations for the Department of Surgery here at Duke. And I'm joined today with Dr. James Jung, assistant professor of surgery, Dr. Zachary Weitzner, our minimally invasive and iatric surgery fellow.

And Dr. Joey Lev, one of our surgical residents. Joey, get us started. Awesome. Let's dive right. Historically, the purview of both endoscopists and surgeons cholo. Dosis has increasingly been tackled in single stage interventions. We do the cholecystectomy, we get rid of the duck stones, and we obviate the need for another intervention when unsuccessful.

ERCP remains an option. But how do we get here? In 1999, a prospective cohort study came out in JAMA Surgery called laparoscopic Common Bile Duct Exploration [00:01:00] Long-Term Outcome. Patients with Cholo diasis that underwent LAP common bile duct exploration, or LAP CBDE were followed with surveys over an average of five years on pain, retained stones and other symptoms.

The rate of failure was exceedingly low, 3%, and retained stones were found in just one patient of the 116 that returned the surveys, but it's still taking time to come into vogue. When I started practicing, we already knew that lapse CBDE was effective, but the norm was still to do the Coley first and ERCP.

Second. It was the exception, not the rule to do it this way. In fact, my practice pattern, since becoming an attending, has been to not do IOC 'cause I don't enjoy doing it. With time that has changed because of my primary specialty in metabolic and bariatric surgery where we have to consider IOC in every patient with surgically altered anatomy.

Sheena. You know, I think you and I are contemporary in when we trained and during the time, you know, I don't think lap CBD exploration was that common or commonly [00:02:00] taught? I think the usual practice had been. If there's high preoperative suspicions for CBD stone, then it would be ERCP first and then perform laparoscopic cholecystectomy.

Or you do laparoscopic cholecystectomy. You have intraoperative finding that are suspicious for CBD stone. Either you do intraoperative cholangiogram and find the stone, but even when you find the stone, it's not that you would jump into A, a laparoscopic CBD exploration, but to stop and then. You know, sent to GI for ERCP.

So that was kind of the usual pattern, at least during kind of our contemporary time. But certainly we're seeing more and more emergence of. Surgeons performing laparoscopic CBD exploration effectively, and this becoming more commonplace with advent of new technologies and so forth. Zach, this paper was published in 1999.

So after this initial paper [00:03:00] demonstrating efficacy of this technique, what came next? So after we've proven the efficacy of the treatment, the natural next step was then to compare it to the existing treatment, which as you guys both mentioned, was ERCP. And so in 2019, there was a meta-analysis that was published in surgical endoscopy that included 12 randomized controlled trials.

And this study looked at ERCP, followed by lap coli in a staged fashion like you guys were talking about. And compared it to lap coli with simultaneous lap common bile duct exploration. The study revealed that a significantly higher rate of pancreatitis in the group that underwent ERCP and both an increased rate of bio leak and poorer stone clearance in the lap, common bile duct exploration group length of stay was also shorter in the single stage group, and mortality was the same between these two groups.

Yeah, so our first study was published in 1999, and then this meta-analysis was published 20 years later. It's obviously accumulated enough RCTs to demonstrate this, but during that time a lot of the [00:04:00] lab CBD exploration techniques are not, we. Perform these days. Right now we, we, a lot of the times rely on the transic approach, but in, in the previous one, there might have been the, the common bile duct approach to exploration and might have included using ttes and things like that that resulted in higher bile leak rates.

Those are something that we should keep in mind when we look at this evidence because the techniques have evolved over the years. It's interesting too, when you look at the actual RCTs included, the more recent studies found equivalent clearance rates. It's possible that comfort and adoption of LAP CBDE or technology has just improved.

It's important though to take a beat here and describe the difference between cystic bile duct exploration and transco docal exploration. Earlier papers, I used a trans colo docal approach where they to make an incision onto the common bile duct between the blood supply in a longitudinal fashion to clear the duct in a couple different ways, either [00:05:00] using typically a fogerty balloon or a sphincter plasty, or a nitinol stent extraction in a basket, and then you close the bile duct over the a t tube.

Which I've done a few times and is not fun to do. I've done it laparoscopically with the help of a HPV surgeon and learns that I don't love managing T tubes. They contribute to higher bio leaks and more complications, wound issues. Transitioning to these transic bile duct explorations has been, I think, impactful not only to my desire to adopt the technique, but also to the outcomes of the patient.

Definitely, and the differences between transy and trans colido bile duct exploration has been studied. There's a 2019 meta-analysis that was published in British Journal of Surgery that looked at 25 studies that examined this topic and found that while trans colido common bile duct exploration had a higher rate of duct clearance than transy approaches.

The cystic exploration yielded shorter duration of surgery, lower bile duct leak rates, and shorter length of [00:06:00] stay with no difference in conversion, stricture formation or reintervention. Trans transy exploration is possible in patients with a cystic duct greater than three millimeters, cystic ducts without angulation.

That would impede passage of a colonoscope ducts with small stones that are less than eight millimeters, and those that are located distal to the cystic duct takeoff for stones that are large. Those that are proximal to the cystic duct takeoff, or in patients whose cystic duct geometry is not favorable to exploration, a trans colido exploration is necessary.

So Dr. Eckhouse, given the evolution in the practice of common bile duct exploration, what's your current practice right now? That's a great question. There's so many new technologies that are coming out that are really fancy and cool to play with. Like the Spyglass scope that is a digital cholo, doco scope that has all the accoutrement needed to clear stone.

It has a great setup. I have actually, while I love that for some of my smaller ducks and patients who have sludge and not stone and don't have. [00:07:00] Obstructing physiology. I'll actually do a transy wire guided sphincter plasty, which was taught to me by my fellow when I was at my previous institution, Maggie Bosley, who's now in practice at OHSU in Portland, Oregon, and my goal is typically to get a five French.

Ure catheter down because I know I can put a wire down it and if I put a wire down it, then I can cell during out the catheter and put in either a. Angioplasty balloon, or I can do spyglass and gives me all the options after I fire a cholangiogram. And I find changing from the kind of standard four French to a five French catheter has been hugely impactful to my efficiency in the operating room.

And the other things that I've learned with. Trying these different technologies with the scope and then using a little older but cheaper technique is port placement becomes really important. And so all these have really evolved me to being primarily a balloon sphincter plasty [00:08:00] surgeon for clearing the common bile duct.

And if that doesn't work or there are larger stones, then I will bring via Seldinger a technique, the spyglass scope. Thanks so much for sharing about your practice. It's interesting to note that every individual surgeon's practice and how they handle these issues is quite different, and that's made studying the outcomes after these procedures quite difficult.

It's worth noting that the quality of the randomized controlled trials that have explored Cystic versus Transco, common duct exploration is quite low. There's very few robust trials in this area. Why do you think this is the case, Dr. Joan? Zach, that's a really important point. High quality, randomized controlled trials comparing transic and trans Coli.

Docal approaches are quite limited, and I think it's largely because of the practical and ethical challenges of performing surgical research. You know, these procedures are highly operator dependent based on their [00:09:00] training where they are availability of the devices. And case selection often dictates the approach.

It's about case selection. For example, smaller stones distal to the takeoff in a dilated cystic duct that's not angulated are far better suited for cystic exploration, whereas the other ones you have to depend on. Trans Chodo approach, it's really hard to randomize to two very different approaches randomizing patients, irrespective of these anatomic or technical factors, risks poor outcomes and the surge of non equi pose.

In addition, the relatively low incidences of Chodo Aias. Hard to do a lot of these operations, stack them up in a day where you could get study coordinators to do randomization and all this stuff. The low incidence requiring exploration makes it really difficult for single centers to achieve adequate sample sizes.

The result most evidence has come from retrospective perspective, core studies, or [00:10:00] relatively poorly performed randomized trials. In April of this year. Irv, you came out called Reclaim the Duct. Laparoscopic common bile duct exploration for the acute care surgeon. Now, obviously a lot of acute cholecystitis and chodo orthosis cholangitis falls on pancreatitis falls under the purview of an acute care surgeon.

About 10 to 15% of the patients coming in with acute cholecystitis at Chodo orthosis. Third view sites lower overall costs, reduce length of stay, reduce post-op bleeding, and less. Pancreatitis has reasons to pursue a single stage approach and includes a range of technical tips, including keeping knowledgeable partners nearby and not underestimating the learning curve.

It's also true that if you bail out, the patient can still get an ERCP. I found this review pretty compelling as a trainee interested in M-I-S-A-C-S. What do you all think about broader adoption? I'm really glad you picked up this article partly 'cause I know the senior author really well. Matt Martin is not only an MIS surgeon, but he is an a CS surgeon.

So it actually lends to your interest really well, [00:11:00] especially considering advanced GI endoscopy is not available everywhere. Having surgeons in the acute care space, being able to clear the duct in a single stage saves the patient time and a potential transfer and risk, as we've discussed. Despite the fact that I think being able to do.

Cystectomy and common bio exploration is the way of the future. There are times when we really need to consider ERCT first, and these are for our patients with acute cholangitis or pancreatitis where we need them to have time to heal from the acute inflammatory process that has occurred with their etiology.

Once they're clinically stable, then they're ready for cholecystectomy. These are patients that I wouldn't want to do as a single stage approach myself, or I wouldn't encourage acute care surgery to do either. Yeah, I, first of all, I think there's increasing role for general surgeons, a CS, surgeons to play a role.

[00:12:00] In fact, Denise G at Mass General and I wrote a opinion piece in the Journal of Trauma and Acute Care Surgery a few years ago about the management of call local ais and just around the role of increasing role of the, the general surgeon to clear out the duct in this single stage approach. But one thing that I would also really advocate for is that you should know when to bail.

You should really know when to stop. And know that you have great partners in GI to perform ERCP postoperatively. So for me. I was never trained in trans colido approach to CBD exploration. So if my Transic approach fails, then I'm not gonna attempt to do trans colido approach for CBD exploration, because that's beyond my expertise, that's beyond my training.

I would say in that way, you just have to know where the limitations are and know when to talk to your [00:13:00] partners. If you have a partner who knows how to do transethical approach, or if you don't have that available, then you communicate this with the GI colleague and they could perform ERCP postoperatively.

And I think all that makes so much sense to me and reminds me that I get to operate on some patients with a little bit different anatomy, where the bailouts have to be a little bit different than just going to an ERCP. So while I agree with you, I don't like doing a trans colido approach. I've done it.

The morbidity is high. If I have the option for an ERCP over a trans approach, I'll probably take it. So in patients with R one Y anatomy, either after bariatric surgery or another procedure, number one IOC is super important. And if you find an obstruction or partial obstruction, I think it's really important to go after it with a common bile duct exploration in a single stage approach.

However, there are times when it's not gonna work, and I've unfortunately experienced those a couple of times now where I either couldn't get the stones out [00:14:00] trans or couldn't push 'em through. In these situations, my bailout is number one, call GI and see if they're able to come into the OR at the time and do a transgastric ERCP on table.

And if that doesn't work, leaving a feeding tube in a, a patient with a ruin wide gastric bypass in the excluded or distal stomach can be a very helpful approach, allowing that to mature and GI can come back and fight another day. The other maneuver or technique that can be used, or instrument that can be used, it's not.

Traditionally talked about is something called a finale stent, which is something you can leave across the sphincter and ULA to allow a path for bile to drain, and GI can come back and pull that out when they do an ERCP in the future if you're not able to completely clear the duct. Not every place has finale stent and they're not the easiest to place, but you place 'em under fluoro.

Ultimately, something you can use as a bailout plan when you're waiting for GI to help you in the future with an ERCP. [00:15:00] It's very interesting to hear about what both Dr. Jung and Dr. Eckhouse are talking about with the tools that we have, as well as the tools that these studies are mentioning for a different bile duct approaches like baskets, balloons, lithotripsy, and finale stents.

Can you guys talk a little bit about what tools we have in our toolboxes to address common bile duct stones, and what do you think that surgeons need to have readily available to clear the duct in most cases? And also I'd like to hear your thoughts on the role of robotic common bile duct exploration as well.

Great question. I think the first step is always giving glucagon. I have a bit of a different approach maybe than the average. I'll split my glucagon dosing from the beginning of the case. I'll start to get things to relax and then give a dose within the five to 10 minutes of doing my common bile duct expiration, and then giving that time to percolate.

I'll do a large flush, typically 20 to 40 ccs. If a flush doesn't work, then my next step is typically to do. A wire guided balloon sphincter [00:16:00] plasty, and I will pick my balloon based on the diameter of the common bile duct, and it'll be anywhere between six and 10 millimeters on average with a length of 40 millimeters.

And I use a 75 centimeter catheter length, so it's easy to get over in a cell dinger fashion. My wire. I'll balloon sphincter plasty for about three to five minutes. The ula, partly to decrease risk of pancreatitis, but also to get enough trauma to the sphincter and ULA to get things to drain through. If that doesn't work, then I go down with a basket and my goal is then to pull each stone out individually with a basket.

Typically, I do this though using the spyglass, and so if I'm not able to balloon sphincter lipoplasty, I'll keep the wire down, pull the angioplasty balloon out. Bring the spyglass in and use a basket under direct visualization, and that has worked for me really well for the last two years. Just to address your last question, Zach, you talked about the use of robotic [00:17:00] platform and as we all know, there's been increasing utilization of robotic platform for all types of procedures, including cholecystectomy and common bile duct exploration.

There is a published study, a single institution case series of 21 patients that came out just in March in the Journal of Society of Laparoscopic and Robotic Surgeons. In this study, there's two of the 21 patients that still needed ERCP postoperatively, but overall, the results were encouraging. But this is again, a case series, single institution, and very limited data.

So something to look out for. Yeah. The authors also mentioned feng shui as a critical component, which I thought was kind of funny, but also very real because manipulating a C-arm and the robot and all the tools you might need, like Dr. Eckhouse mentioned to do this successfully is no small task. Yeah, having your staff on the same page, even during a dry run is really critical.

Maybe do a dry run the day before, but the big thing is if you don't have time for [00:18:00] that touch base with your resource nurses. Make sure you have everything you need available and go into the operating room. Before the patient rolls back and touch base with your team, make sure they have all the equipment you think you could need.

Think outside the box, go down that path and make sure all of it's in the room so that they're set up for success. And then I think talking to the staff about not only what you expect to go well, but what you're concerned about and what you think you're gonna need to do really helps them navigate what the steps are gonna be in the moment.

Now, obviously you wouldn't do the duct exploration robotically if you were doing your cholecystectomy laparoscopically and a 2023 JAMA Surgery. Paper comparative safety of robotic assisted versus laparoscopic cool cystectomy. Looked at just over a million patients and found that though robot use has increased 37 fold since 2010, it's still only about 150,000 of those million.

And interestingly in that paper, robotic assisted cholecystectomy had a higher rate of common bile duct injury than [00:19:00] lap coli at 0.7% compared to 0.2, which could be due to a number of different factors possibly related to robot learning curve or some other unknown factors that we're not able to yet appreciate.

I think that one of the most important things is that robotic surgery has opened a platform that allows us to do open style procedures on patients in a MIS fashion that we weren't necessarily able to do. Um, as easily laparoscopically, and I'm curious to hear your thoughts, Dr. Jung, about how the robotic platform will translate to trans cholo docal exploration.

Yeah, I think as it was highlighted in that landmark paper in JAMA Surgery, just looking at the short term outcomes, safety, outcomes of robot versus lab cholecystectomy, again, cholecystectomy. Is a relatively simpler procedures that we commonly perform, but just by changing the platform, we're seeing a, at least statistically significant and somewhat clinically significant difference in postoperative [00:20:00] outcomes.

And, and I think really reason for that is we tend to underestimate the learning curve that's involved in transitioning from lab to robot or for some people open to robot. And that's something that should be taken very seriously when deciding to perform a procedure that you know how to do in one platform and transitioning to another platform.

Especially if the procedure is as complex as common bio exploration that involves different types of devices concurrent to the new device of robotic platform that you're using. You really need to, you know, make sure that you get enough. Adequate training support, not only for yourself as a surgeon, but also your perioperative team that involves your scrub tech, your circulating nurses, your assistants anesthesiologists.

'cause otherwise it's very hard to coordinate all of these together. And for me, I think it's really. You as a surgeon [00:21:00] is just overburdened with cognitive load of trying to deal with all different moving pieces of doing all of this together at once, and that increased cognitive load may lead to and translate towards clinical outcomes.

So be really careful when you're transitioning to new platform. Be aware of the learning curve, the steep learning curve that's involved. Don't underestimate it. Yeah, these are really important points and as I think about the learning curve, I'm thinking about the learning curve, both for common bile duct exploration and for robotic surgery, which I've done both now and marrying them together is a sensing you really wanna be cautious of.

I didn't learn common bile duct exploration as a trainee. I learned it in practice my second year out, and I still remember making sure the first time. Running through everything, just like we've talked about with the team ahead of time, but also with one of my partners and having a partner available to help me.

Even though everything went well, my two partners were there. One learning and one [00:22:00] teaching just to make sure we crossed our T's and dot our i's and made sure the patient was safe and successful. I've adopted that also with my robotic journey as well, even though I do both. And so understanding how to adopt common bile duct exploration can be different for you.

One of the best things that has been. Helpful for me is having somebody I can call after each common bile duct exploration to talk through what went well, what were my opportunities, and how I could change to improve my efficiency and success has been really helpful with moving forward with some of the newer techniques and adoptions that I've been able to make.

Overall, I think the learning curve of surgeons taking back the common bile duct is a fascinating one that we're watching an evolution right now. This has been an overview of surgical management from our perspective of Chodo ais from your MIS team. We hope you've had fun. Look forward to seeing you next time.

Now get your cholo doco scope ready and dominate the day.