ThP4.12 - Impacted Bile Duct Stones Encountered during 1447 Laparoscopic Explorations; Incidence and Management

Aim To study the incidence and management of impacted bile duct stones encountered during laparoscopic bile duct exploration (LCBDE). Methods A review of patients undergoing LCBDE for impacted stones. Preoperative imaging, operative difficulty grading, impaction location, dis-impaction methods, operative complications and postoperative outcomes were analysed. Results 136 of 1447 (9.4%) LCBDEs had impacted stones; median age 53 years, 63.2% females. 88.2% were emergencies; 94 Jaundiced (69.1%). USS showed CBD dilatation in 30.1%. 16.9% had previous ERCP and 43% previous biliary admissions. CBD exploration was transcystic in 52 (38.2%) and via choledochotomy in 84 (61.8%). LCBDE difficulty grading was IV in 61 (44.9%) and V in 75 (55.1%). The number of stones ranged from 1-70 (mean 6, median 2) and stone size 4-30mm (median 12). All needed choledochoscopy. Impaction was at lower CBD in 83 (61%), Mid-CBD 29 (21.3%), Intra-hepatic 15 (11%), intra and extra hepatic in 6 (4.4%) and intramural in 3. Dis-impaction needed biopsy forceps/grasper fragmentation (45.6%) basket/Fogarty manipulation in 35.3%, laser in 8.8%, pushing stones using the choledocoscope in 6 cases (4.4%) and conversion or leaving stone for ERCP in 7 (5.8% 6 prior to1997). The median operative time was 150 minutes (60-630 minutes). Complications occurred in 33 (24.2%) including15 biliary-related and 9 biliary drain-related. Readmissions occurred in 18 patients (11 biliary-related) and one death was caused by pneumonia. Hospital stay median was 10 days (3 to 54). On 80% follow up the presentation to resolution period median was 2 weeks (1- 30). Conclusions Apart from CBD stones shown on USS and failed ERCP this study identified no obvious risk factors.