Fanelli Laparoscopic Endobiliary Stent

1
FanelliLaparoscopic Endobiliary Stent

• Robert D. Fanelli, MD, FACS
• Assistant Professor of SurgeryUniversity of
  Massachusetts Medical SchoolDirector of Surgical
  EndoscopyBerkshire Medical Center

2
Laparoscopic Endobiliary Stent Placement

• Eliminates need for T-tubes, cystic duct
  catheters, external drains when Laparoscopic
  Transcystic Common Bile Duct Exploration (LTCBDE)
  or Laparoscopic Common Bile Duct Exploration
  (LCBDE) performed
• Eliminates need for LTCBDE or LCBDE for Common
  Bile Duct Stones (CBDS)
• Protects ductal closures, limits risks of bile
  leak

3
Laparoscopic Endobiliary Stent Placement

• Prevents complications associated with retained
  CBDS
• Virtually assures success of postoperative ERCP
• Necessary equipment inexpensive, readily
  available
• Suitable for use in ASCs as well as hospitals

4
Laparoscopic Endobiliary Stent Placement

• First described as adjunct to LCBDE, eliminating
  T-tubes
• 16 patients (1993-1995)
• 100 clearance CBDS by LTCBDE and LCBDE
• No bile leaks, complications
• 36 to 72 hour LOS
• Gersin, Fanelli.Surgical Endoscopy, vol.12
  (4),April 1998 p. 301.

5
Laparoscopic Endobiliary Stent Placement

• Most surgeons rely on postoperative ERCP for CBDS
• Patients face risks of retained CBDS,
  pancreatitis, cholangitis, stump leak
• ERCP results vary based on volume
• High volume centers, gt 95 selective cannulation
  rate
• Low volume centers, lt 60 selective cannulation
  rate
• Average rates of selective cannulation, 80 to 85
• 20 patients face reoperation, PTC, or referral
  for second ERCP for CBDS left at time of LC
• Conversion, T-tubes, drains deprive patients of
  low morbidity, quick recovery of LC
• T-tubes, drains require constant management,
  delay discharge

6
Laparoscopic Endobiliary Stent Placement

• Our current experience (SSAT Scientific Session,
  May 2000)
• 372 consecutive LC during 36 months, ending July
  1999
• Hasson cannula, three 5 mm upper abdominal ports,
  general anesthesia, CO2 insufflation, routine
  fluorocholangiography (FC)
• FC accomplished in all patients
• CBDS or suspicious FC identified in 48 (12.9)
• No attempt made to clear CBDS, all patients
  treated with stents
• Stent placement added 9 to 26 minutes to LC
  operative time
• Cystic duct balloon dilation necessary in 14
  (29.2)
• Laparoscopic suturing, advanced skills were not
  utilized

7
Laparoscopic Endobiliary Stent Placement

• Hemorrhage, bile duct injury, duodenal
  perforation, sub-optimal stent placement, stent
  migration did not occur
• Longest f/u 46 months original series, 80 month
  f/u
• 44 (92) treated as outpatients
• 4 (8) admitted overnight with average LOS 30
  hours
• Indications for admission
• PONV (2)
• surgery completed too late for discharge (1)
• weather too severe for safe discharge (1)
• Outpatient ERCP with ES 1 to 4 weeks later
• 100 successful for clearance of CBDS
• CBDS found in all patients -- no false positive
  FC
• No ERCP, stent related complications to date,
  including pancreatitis

8
Laparoscopic Endobiliary Stent Technique

• Routine FC via epigastric port
• Flexible tip cholangiogram catheter with
  three-way adapter
• Three-way adapter permits saline, contrast
  injection, and placement of wire guide

9
Laparoscopic Endobiliary Stent Technique

• 150 cm Tracer Hybrid Wire Guide advanced through
  cholangiogram catheter
• Wire guide positioned across ampulla, past CBDS
• Cholangiogram catheter, removed over wire guide
• Finger occlusion of epigastric port prevents loss
  of CO2
• Stent introducer port can be used if desired
• Cystic duct dilated if necessary

10
Laparoscopic Endobiliary Stent Technique

• Continuous fluoroscopy
• Stent assembly advanced over wire guide
• Position stent across ampulla
• Radiographic markers assure proper positioning
• Stent is fixed to delivery mechanism
• Stent location adjusted as needed prior to
  deployment
• Once position perfect, release safety to prepare
  for deployment

11
Laparoscopic Endobiliary Stent Technique

• Radiographic markers
• Marker 1 - distal tip
• Marker 2 - distal flange
• Marker 3 - proximal flange
• Marker 4 - proximal tip
• Markers signal deployment
• Markers 3, 2, and 1 pass through 4 during release
• After 3, 2, and 1 clear 4, stent is free of
  delivery system

12
Laparoscopic Endobiliary Stent Technique

• Stent successfully deployed
• Positioned across ampulla
• Contrast rapidly drains from CBD
• Cystic duct ligated
• Cholecystectomy completed
• Drains are not placed
• Patient is discharged when alert
• Placement of stent added 20 minutes to LC
  operative time

13
Laparoscopic Endobiliary Stent Technique

• ERCP 1 to 4 weeks postop
• Same admission feasible
• Various ERCP methods
• Snare removal of stent prior to cannulation,
  sphincterotomy
• Wire guide placed via stent prior to retrieval
• Precut sphincterotomy over stent
• Cannulate beside stent for sphincterotomy
  (preferred method)

14
Laparoscopic Endobiliary Stent Kit

• Stent and pusher assembly
• 150 cm Tracer Hybrid Wire Guide
• Additional Components
• Introducer set
• 12 French cystic duct dilation balloon
• Cholangiogram catheter with three-way adapter,
  short wire

15
Conclusions

• There are numerous methods for treating CBDS
  during LC
• LCBDE is quick and highly successful, but
  requires refined laparoscopic suturing skills and
  carries risks of choledochotomy
• LTCBDE is time consuming, requires expensive
  equipment and endoscopic, fluoroscopic skills,
  but avoids choledochotomy
• Both employ external drains, T-tubes, or cystic
  duct catheters
• Laparoscopic stent placement is fast, involves
  minimal expense, does not require
  choledochotomy, eliminates external tubes and
  drains, and virtually assures success of
  postoperative ERCP

16
References

• Gersin KS, Fanelli RD. Laparoscopic Endobiliary
  Stenting as an Adjunct to Common Bile Duct
  Exploration. Surg Endosc 1998 Apr12(4)301-304.
• Fanelli RD, Gersin KS. Laparoscopic Endobiliary
  Stenting A Simplified Approach to the Management
  of Occult Common Bile Duct Stones. J Gastrointest
  Surg 2001 Jan/Feb 5(1)74-80.
• Fanelli RD, Gersin KS, Mainella MT. Laparoscopic
  Endobiliary Stenting Significantly Improves
  Success of Postoperative ERCP in Low Volume
  Centers. Surg Endosc 2002 Mar16(3)487-491.
• Wu JS, Soper NJ. Comparison of Laparoscopic
  Choledochotomy Closure Techniques. Surg Endosc
  2002 Sep16(9)1309-1313.