Laparoscopic cholecystectomy with non-X-ray endoscopic retrograde cholangiopancreatography for simultaneous common bile duct stone extraction

Dear Editor With the development and advance of medical techniques, various methods exist for the treatment of gallbladder (GB) stones and common bile duct (CBD) stones, mainly including laparoscopic cholecystectomy (LC) combined with endoscopic retrograde cholangiopancreatography (ERCP), which is the preferred intervention1,2. Because the X-ray is not always available in the operating room, the LC and ERCP have to be performed separately in two stages. As we previously suggested the visualized biliary cannulating technique during ERCP with the help of the cholangioscopy to simplify the above staging surgery into a single-stage operation, we have established the single-stage operation performing LC and ERCP to treat both GB and CBD stones simultaneously, without the utilization of X-ray. Figure 1 shows a 72-year-old man with GB and CBD stones who developed a right upper quadrant abdominal pain and was referred to minimally invasive surgery. Magnetic resonance cholangiopancreatography (MRCP) identified a 6-mm stone located in the non-dilated CBD, which could not be removed by laparoscopic CBD exploration. Therefore, LC combined with ERCP was planned to treat this patient. First, under laparoscopy, Calot’s triangle was dissected, the cystic artery ligated and cut-off, then the cystic duct was clipped to prevent GB stones falling into the CBD (Fig. 1a). The CBD was then successfully cannulated under duodenoscopy using a sphincterotome independent of X-ray (Fig. 1b). When the yellow bile was sucked into the sphincterotome, a small sphincterotomy and endoscopic papillary balloon dilation were conducted. The cholangioscope was inserted into the CBD and revealed the presence of a small stone (Fig. 1c). The stone was directly extracted using a slim basket under cholangioscopy (Fig. 1d). Following repeated confirmation of a clean CBD cavity by the cholangioscope (Fig. 1e), the cystic duct was transected and the GB was completely resected (Fig. 1f). The patient recovered very well and was discharged without any remaining stone residues confirmed by MRCP. Combination of laparoscopy, duodenoscopy and cholangioscopy independent of X-ray in the single-stage treatment of GB and CBD stones a Dissection of Calot’s triangle, cystic artery ligation, and cystic duct clamp were performed during the laparoscopic procedure. b The CBD was cannulated under duodenoscopy using a sphincterotome without the assistance of X-ray imaging. c The cholangioscope was introduced into the CBD, which confirmed the existence of stones. d The stones were then promptly extracted utilizing a slim basket under cholangioscopy. e After multiple attempts of saline irrigation, a clean CBD cavity was verified under cholangioscopy, f the cystic duct was cut-off and the GB was entirely excised. This is the first report of a single-stage surgery of LC and ERCP independent of X-ray in treatment of GB and CBD stones. An inspired observation we gained from these earlier studies, our pilot study has demonstrated an innovative practice for the treatment of concomitant GB and CBD stones. This novel surgical strategy is facilitated in the same period avoiding fractionated therapy, especially for patients who cannot tolerate X-ray. Compared to conventional treatment options, the advanced skill offers greater time savings, which could be performed independent of X-ray in a general operating room. Furthermore, the cholangioscopy providing direct vision is a stable guarantee of stone removal, thereby reducing the risk of residual stone fragments and stone recurrence3–5. In conclusion, our experience demonstrates the safety and feasibility of this innovative technology and this single-stage therapy may be referred to as a novel alternative therapeutic strategy for patients with GB and CBD stones in the future. Study concept and design (Wei-hui Liu); acquisition of data (Ren-yi Zhang, Wei-hui Liu, Qiang Guo, Ji Zhao); analysis and interpretation of data (Wei-hui Liu, Qiang Guo); drafting of the manuscript (Wei-hui Liu, Qiang Guo, Ji Zhao); critical revision of the manuscript for important intellectual content (Wei-hui Liu); technical material support (Wei-hui Liu); study supervision (Wei-hui Liu) The authors have no funding to declare. Q.G., J.Z., and R-y.Z. contributed equally to this work. There is no conflict of interest to declare for all of the authors. Supplementary material is available at BJS online. All crude data are available in the article and in its online Supplementary material.