Multicenter Study of Laparoscopic Common Bile Duct Exploration for Choledocholithiasis in the English-Speaking Caribbean

Background Common bile duct (CBD) exploration to address choledocholithiasis is not widely practiced in the English-speaking Caribbean. This study sought to determine the frequency of laparoscopic CBD explorations in the English-speaking Caribbean and to document the stone clearance rates and short-term outcomes of this procedure. Methods We accessed records for all practicing laparoscopic surgeons in the English-speaking Caribbean who performed laparoscopic CBD explorations over a 10-year period from January 1, 2013, to June 30, 2023. The following data were extracted retrospectively from patient records: demographic details, operating time, stone clearance rates, retained stone rates, conversions, and complications. All data were analyzed with SPSS version 20 (IBM Corp., Armonk, NY). Results Over the 10-year study period, 35 patients underwent laparoscopic cholecystectomy and synchronous CBD exploration in Barbados, Cayman Islands, Guyana, Grenada, St Lucia, and Trinidad & Tobago. The procedure was performed at low volumes of only 0.7 procedures per surgical team per annum. The conversion rate to open CBD exploration was 13% and when laparoscopic CBD exploration was completed, it resulted in 96.3% stone clearance, 3.7% retained stones, mean hospitalization of two days, 9.7% minor morbidity, and no mortality. Conclusion Laparoscopic CBD exploration is feasible in the resource-poor Caribbean setting, and it yields good results, with 96.3% stone clearance rates, 9.7% minor morbidity, and no mortality. These results are better than those reported in Caribbean literature for stone extraction with endoscopic retrograde cholangiopancreaticography (ERCP).


Introduction
Common bile duct (CBD) exploration to address choledocholithiasis was a routine procedure in the era of open surgery but is less popular among laparoscopic surgeons [1].A similar scenario exists in Caribbean practice, where surgeons are generally reluctant to perform CBD exploration at the time of laparoscopic cholecystectomy, instead deferring to two-staged treatment with pre-operative endoscopic retrograde cholangiopancreaticography (ERCP) prior to laparoscopic cholecystectomy [2].
In a few centers in the English-speaking Caribbean, laparoscopic CBD explorations are performed for stone extraction.This study sought to determine the frequency of laparoscopic CBD explorations for choledocholithiasis in the English-speaking Caribbean and to document the stone clearance rates and shortterm outcomes with this procedure.The Anglophone Caribbean consists of 17 countries, with a cumulative population of 6,426,914 persons [3]: Anguilla, Antigua & Barbuda, Bahamas, Barbados, Belize, British Virgin Islands, Cayman Islands, Dominica, Grenada, Guyana, Jamaica, Montserrat, St. Kitts & Nevis, St. Lucia, St. Vincent & the Grenadines, Trinidad & Tobago, and Turks & Caicos.All surgeons in these nations are fellows of the Caribbean College of Surgeons (CCOS), founded in 2002 as a professional association to promote surgical education for general surgeons practicing in the Anglophone Caribbean [3].Therefore, approval for this study was sought from and granted by the CCOS.

Materials And Methods
We contacted the CCOS' general membership by email and/or telephone to identify practicing surgeons who performed laparoscopic CBD exploration for choledocholithiasis.Surgeons performing laparoscopic CBD explorations were invited to participate by reporting their data.All data were cross-checked by retrospectively examining records from operating theaters in each of the English-speaking Caribbean countries over a 10-year period from January 1, 2013, to June 30, 2023.Any patient who underwent laparoscopic CBD exploration was identified and their records were retrieved for detailed analysis.The following data were extracted: demographic details, operating time, stone clearance rates, retained stone rates, conversions, and complications.All data were entered into a Microsoft Excel database (Microsoft Corporation, Redmond, WA) and the data were analyzed with SPSS version 20 (IBM Corp., Armonk, NY).
We defined stone clearance as the removal of all stones within the CBD after duct manipulation, confirmed on cholangiography or choledochoscopy.A retained stone was considered as one that was detected in the CBD less than six months after cholecystectomy [4].Recurrent CBD stones were defined as those detected more than six months following cholecystectomy [4].

Results
Over the 10-year study period, 35 patients underwent laparoscopic cholecystectomy and synchronous CBD exploration.There were 31 females and 4 males at a mean age of 47.1 years (Range 23-68; SD ±11.9;Median 49).The teams performing laparoscopic CBD exploration were located in Barbados, Cayman Islands, Guyana, Grenada, St Lucia, and Trinidad & Tobago.Thirty-four patients underwent conventional laparoscopic explorations and 1 underwent FreeHand® robot-assisted laparoscopic exploration.Paper-based records could not be located for four patients, and these cases were excluded from further analysis.The final study sample comprised 31 patients who underwent laparoscopic CBD explorations.
In this setting, routine cholangiography was not practiced.We performed selective cholangiography when prompted by the presence of jaundice or deranged liver function tests.In 22 (71%) patients, choledocholithiasis was diagnosed preoperatively on imaging as prompted by clinical symptoms and/or abnormal liver function tests, and the diagnosis was only made intraoperatively in nine (29%) patients (Figure 1).The average CBD stone burden was 4.5 stones (Range 1-12; SD ±3.9; Median 3), but the stone size was not consistently recorded.

FIGURE 1: Patients Undergoing Laparoscopic Cholecystectomy, Operative Cholangiography, and Common Duct Exploration for Stone Extraction
Exploration of the CBD was attempted via the trans-cystic route in 15 cases (the mean stone burden in this group was 4.6 stones per patient), but four of these patients required a choledochotomy when stones could not be retrieved by the trans-cystic route.In total, 20 patients had exploration via choledochotomy (the mean stone burden in this group was 3.43 stones per patient).In these patients, CBD stones were extracted using a combination of approaches, including Fogarty or Foley catheters (18), Dormia baskets (11), and stone advancement (6) using irrigation and/or a choledochoscope.The biliary tree was repaired with laparoscopic sutures in all cases, and T-tubes were only utilized in three (9.7%)cases.
There were four (13%) conversions to open CBD exploration for failed attempts at laparoscopic stone extraction.In this group, the patients had stones proximal to the cystic duct junction (2) and heavy stone burden (>8 stones) in the CBD (2).The surgeons completed laparoscopic CBD exploration in the remaining 27 (87.1%)cases.
A total of 27 patients had laparoscopic CBD exploration completed.Two (7.4%) patients in this series had bile leaks post-operation.In both patients, the bile leaks settled with drainage through 15 Fr Blake drains that were placed in Morrison's pouch at the time of operation.None of these patients required postoperative ERCP and/or surgical intervention.
One (3.7%) patient in this series had a retained stone.This was a 30-year-old female who had undergone a prior failed attempt at ERCP.At laparoscopy, two stones were retrieved via a choledochotomy.A cholangiogram was done post-exploration.The operative note documented that it was of "poor quality," and the surgeon interpreted that the CBD was clear post-exploration.This patient was identified post-operation when she re-presented with jaundice and abnormal liver function tests.

Discussion
In Caribbean practice, ERCP is not readily available [5].A prior report from the CCOS documented that ERCP was readily available in only four (24%) countries in the Anglophone Caribbean up to the year 2023 [5].
Considering that choledocholithiasis is present in 3-10% of patients undergoing laparoscopic cholecystectomy [6], it is probably a skill that laparoscopic surgeons in the Caribbean should acquire.
In the Caribbean, many patients are transferred to the four nations in which ERCP is available for preoperative endoscopic stone extraction prior to laparoscopic cholecystectomy.This, however, may not be in the best interest of the patients, as they are exposed to two-staged treatment, multiple exposures to anesthesia, increased cost, and treatment delays.On the other hand, when Pan et al. compared preoperative ERCP and subsequent laparoscopic cholecystectomy to single-stage laparoscopic cholecystectomy with CBD exploration in 1,757 patients with CBDS across 13 trials, they demonstrated the inferiority of the two-staged treatment [7].Those patients who underwent synchronous laparoscopic CBD exploration and cholecystectomy had greater stone clearance (94% vs 90%), lower treatment costs, lower morbidity (7.6% vs 12%), less retained stones (1.2% vs 7.9%), lower cumulative operating time (112 vs 132 minutes), and reduced hospitalization (4.9 vs 6.6 days) [7].

Table 1
documents the clinical outcomes in this group of patients.