Clinical Study On Serial Scheme Of Mini-invasive Surgical Treatment For Extrahepatic Bile Duct Stone Disease

Objective: To study the most appropriate approach to treat extrahepatic bile duct stone disease by duodenoscopy, laparoscopy and choledochoscopy . And establish a serial standardized scheme of mini-invasive surgical treatment for extrahepatic bile duct stone disease.Methods: 1983 patients with extrahepatic bile duct stones were treated from Jun.1998 to Dec. 2002. Among the patients, fifty cases were randomly selected to perform open common bile duct exploration and T-tube drainage for case-control study. The rest cases were underwent the treatment of duodenoscopy at first. According to the outcomes of the treatment of endoscopy and the special conditions of extrahepatic bile duct stones, we proposed a series of schemes,i.e.,a scheme of uni-scopy,one of bi-scopy and one of tri-scopy.Among the patients whose extrahepatic bile duct stones had been taken out, there involved in two conditions. If the patients didn't accompany cholecystolithiasis, they could go home. But if the patients accompanied cholecystolithiasis, they must undergo laproscopic cholecystectomy(LC). The first treatment method is the scheme of uni-scopy,and the second one is called the scheme of bi-scopy(1) (combination of duodenoscopy and laparoscopy). According to the patients whose extrahepatic bile duct stones couldn't be taken out by duodenoscopy,we admitted the scheme of tri-scopy (combination of duodenoscopy,laparoscopy and choledochoscopy), i.e. endoscopic nasobiliary drainage (ENBD) was first adopted and followed by laparoscopy common bile duct exploration, finally, intraoperative choledochoscopy was used to clear thestones. So,we can suture the incision of the common bile duct primarily.But ,if ENBD failed, we performed laparoscopic common bile duct exploration ,and then extracted the stones by choledochoscopy, and finally placed T tube drainage.This scheme we called bt-scopy(2)(combination of laparoscopy and choledochoscopy).The success rate and post-operative results of the mini-invasive treatment group were observed and analyzed compared with the outcome of the control group.Result: Satisfactory outcomes were obtained.Among 357 patients who underwent the scheme of uni-scopy, 325(91.04%)were successful.The scheme of bi-scopy (1) resulted in success in 1349 of 1576(85.60%). The scheme of bi-scopy (2) resulted in success in 35 of 39 (89.74%).The success rate is 95.32% in those 171 cases who were received the scheme of. tri-scopyWe have perfromed the four schemes for various conditions of extrahepatic bile duct stones step by step. The overall success rate was 98.19%(1898/1933). There were not serious post-operative complications.The success rate of this serial standardized scheme of mini-invasive surgical treatment was higher than the laparotomy treatment group. The patients were pain less and recovery faster. So, the postoperative hospitalization period was much shorter than open choledocholithotomy.Conclusion: This serial scheme utilizes the advantages of techniques of digestive endoscopies and laparoscopy and shows fully the characteristics of mini-invasive surgical means. The results of this study indicate that this serial scheme is practicable and safe by well-trained endoscopic and laparoscopic surgeons in biliary surgery. It is surperior to open choledocholithotomy.We conclude that the most appropriate management approach for extrahepatic bile duct stone disease depends on the outcomes of the treatment ofduodenoscopy and that if the patients accompany cholecystolithiasis at the same time. So,we have devided into four schemes step by step in clinical application for various conditions of extrahepatic bile duct stone disease.This serial scheme has expanded the therapeutic scope of mini-invasive surgery for complicated choledocholithiasis and elevated the success rate. So, itmakes the treatment methods more integrity and standard.