Nghiên cứu ứng dụng phẫu thuật nội soi mở ống mật chủ lấy sỏi điều trị sỏi đường mật chính tại bệnh viên đa khoa kiên giang tt tiếng anh

Evaluating the results of laparoscopic choledocholithotomy combined with cholangioscopy in treating biliary tract stones at Kien Giang General Hospital.. Some new contributions of thesis

MILITARY MEDICAL UNIVERSITY

SU QUOC KHOI

APPLIED RESEARCH OF LAPAROSOCPIC CHOLEDOCHOLITHOTOMY TO TREAT BILIARY TRACT STONES IN KIEN GIANG

GENERAL HOSPITAL

Speciality: Surgery Code: 9 72 01 04

SUMMARY OF MEDICAL Ph.D THESIS

HA NOI – 2019

HÀ NỘI-NĂM

MILITARY MEDICAL UNIVERSITY

Scientific supervisors:

1 NGUYEN VAN XUYEN, Ph.D, Assoc.Prof

2 DANG VIET DUNG, Ph.D, Assoc.Prof

Reviewer 1: Nguyen Tien Quyet, Ph.D, Assoc.Prof

Reviewer 2: Nguyen Anh Tuan, Ph.D, Assoc.Prof

Reviewer 3: Le Trung Hai, Ph.D, Prof

The Thesis will be defended against the Council of Military Medical University at:

This thesis can be referred at:

- National Library of Vietnam

- Library of Military Medical University

INTRODUCTION

Biliary stones is a common disease in Vietnam as well as in the world Biliary stones in our country are usually primary stones, formed in place, in large numbers, large size, many positions, high rate of intrahepatic stones and recurrence

Treatment of biliary tract stones has many different methods but up to now surgery still plays an important role Currently, in our country the biliary tract stones are treated mainly by open surgery, choledocholithotomy and draining Kehr tube

Laparoscopic surgery is a new revolution in surgery In 1990, Stoker was the first surgeon to perform laparoscopic choledocholithotomy to treat biliary tract stones Subsequently, many reports of Berthou, Grubnik, Petelin gave good results, the rate of stone clearance from 92 to 96.7% with low accidents and complications

Biliary tract stones in our country have different characteristics compared to European - American countries, so even though laparoscopic surgery has advantages such as less pain, quick recovery, but application of laparoscopic surgery to treat primary biliary stones is difficult about indications, surgical technique and especially being to detect and clean stones intraoperative cholangioscopy increases the rate of detecting stones and stone clearance However, the applied research of laparoscopic surgery combining with intraoperative cholangioscopy to to treat bilary tract stones are few, with a small case volumme Therefore, much more research is needed to apply this technique well, especially at the provincial level, which is difficult due to limitations in equipment, qualifications and laparoscopic skills In Kien Giang, laparoscopic

surgery for biliary tract stones treatment has not been applied So we carry on research: “Applied research of laparosocpic

choledocholithotomy to treat biliary tract stones in Kien Giang General hospital ” to aim for the following objectives:

1 Determination of indications and technical characteristics

of laparoscopic choledocholithotomy combined with cholangioscopy in treating biliary tract stones

2 Evaluating the results of laparoscopic choledocholithotomy combined with cholangioscopy in treating biliary tract stones at Kien Giang General Hospital

Some new contributions of thesis:

- Determination of some main indications of laparoscopic choledocholithotomy combined with cholangioscopy in treating biliary tract stones

- Determination of technical characteristics of laparoscopic choledocholithotomy combined with cholangioscopy in treating biliary tract stones

- Proving the safety and efficacy of laparoscopic choledocholithotomy combined with cholangioscopy in treating biliary tract stones: high successful rate, increasing rate of stone clearance

Frame of thesis

The content of the thesis is presented in 123 pages, including

4 chapters Introduction in 2 pages Chapter 1 - Overview in 32 pages Chapter 2 - Objects and methods in 21 pages Chapter 3 – Results in 27 pages Chapter 4 - Discussion in 31 pages Conclusion

in 2 pages Proposal in 1 page The thesis has 44 tables, 26 images, 6 charts References in 120 documents

Chapter 1 OVERVIEW 1.4.3 Laparoscopic surgery to treat biliary tract stones

Two main methods of Laparoscopic surgery to remove biliary tract stones:

+ Transcystic stones extraction

+ Removing stones via choledochotomy

In addition, some another methods of laparoscopic surgery are indicated for the treatment of primary biliary stones such as: laparoscopic liver resection, hepaticojejunostomy

1.5.2.2 Cholangioscopy in laparoscopic surgery

The removal of stones using a tool based on the surgeon's experience to determine whether or not it has been cleared is difficult Using flexible cholangioscopic technique helps overcome this disadvantage Cholangioscopy in laparoscopic surgery can perform transcystic duct or incision of choledochotomy

In 1990, Stoker performed a flexible cholangioscopy in laparoscopic surgery for good results

In 2007, Nguyen Hoang Bac performed intraoperative cholangioscopy for 167/168 cases, with result detecting 53.6%

remained stones after removing stones by instruments

In 2010, Nguyen Khac Duc performed cholangioscopy for 12/158 cases and determined intraoperative stone clearence No the number of these patients has remained stones in postoperative time

Cholangioscopy not only diagnoses remnant stones but also helps surgeons choose and use measures to take stones such as using basket, lithotripsy, tools, washing to lower the rate of postoperative retained stones Besides, cholangioscopy as a means to help surgeons

to identify intraoperative stone clearance, bile duct mucosa and narrowed bile ducts, thereby deciding to close common bile duct

1.6 Laparoscopic surgery to treat biliary tract stones in the world

The main biliary stones in Western countries are usually secondary stones, from the gallbladder falling down, so the stones are usually small, not many tablets, usually common bile duct stones combine with gallstones, stones in low section of CBD and no intrahepatic stones, so transcystic stone extraction is very high, 50.4-82.5% In contrast, Asian authors have a lower rate of transcystic stone extraction

The research and application of laparoscopic surgery to treat biliary tract stones have made much more progress and indication to have been expanded In addition, many studies have control groups to determine the advantages of laparoscopic surgery treating biliary tract stones were perfomed

The main biliary stones in Western countries are usually secondary stones, small size, not many tablets, usually common bile duct stones combine with gallstones and no intrahepatic stones Intraoperative cholangioscopy to detect, remove stones or lithotripsy

is performed routinely and almost 100% of cases of laparoscopic

surgery However, cholangioscopic scope can be performed by specialized flexible scope, rigid endoscopic scope, uterorenoscope or bronchoscope

1.7 Laparoscopic surgery to treat biliary tract stones in Viet Nam

In 1999, the hospital of Ho Chi Minh City University of Medicine and Pharmacy performed laparoscopic surgery to treat biliary tract stones by technique using intraabdominal air insufflation and extract stones via transcystic duct and choledochotomy

Table 1.6 Laparoscopic surgery to treat biliary tract stones in

Viet Nam

Author n Success (%) Complication (%)

Nguyen Hoang Bac (2007) 168 97,7 6,4

Nguyen Khac Duc (2010) 128 86,49 3,9

It can be said that since 1998 up to now, the laparoscopic surgery for biliary stones treatment consist of 3 main studies, which are indicated for cases, using many techniques to treat stones

Regarding indications, there are many different indications: Nguyen Hoang Bac, Nguyen Khac Duc indicate for reoperative cases but the number of authors is only 15 cases; indications for extrahepatic stones are performed by Nguyen Hoang Bac, Nguyen Khac Duc, Tran Manh Hung Nguyen Hoang Bac appointed for cases

of simple choledocholithiasis with size of stone ≥ 20mm Nguyen Khac Duc, Tran Manh Hung only required stone diameter from 8mm to10mm Indications of laparoscopic surgery for simple choledocholithiasis, failure of ERCP were performed by 3 authors

but in few numbers Besides, Nguyen Hoang Bac also indicated for intrahepatic stones with a low rate of 33.1%

Technical characteristics: Nguyen Hoang Bac performed the removal of stone through cystic duct with the number of 10 cases and through choledochotomy, hepatectomy to intrahepatic stones Nguyen Khac Duc and Tran Manh Hung only performed choledocholithotomy for extrahepatic biliary tract stones Regarding primary closure, no bile drainage was conducted by all 3 authors In terms of cholangioscopy combined with laparoscopic surgery: Tran Manh Hung did not perform, Nguyen Khac Duc, Nguyen Hoang Bac did not perform all cases due to a broken scope This is one of the general limitations of studies

Surgical results when pooled analysis including cases of internal and extrahepatic stones, first surgery and reoperation, transcystic stone extraction and choledocholithotomy, drainage and none drainage: Laproscopic surgery to treat biliary tract stones has a success rate ranging from 86.5% to 99.0% The rate of converting to open surgery varies from 1% to 13.5% Intraoperative accidents 1.2 - 2.75% Postoperative complications 3.91 - 7.6%

The characteristics of biliary stone in Vietnam are different from those of Europe and America The author choose choledocholithotomy instead of removing stones through cystic duct laparoscopic surgery has many advantages, but it is necessary to combine intraoperative cholangioscopy to increase the efficiency of stone clearance However, at present, there are few studies evaluating the method of laparoscopic surgery combining with intraoperative cholangioscopy to treat main biliary tract stones This is an urgent need, contributing to improving treatment effectiveness so we do this research

Chapter 2 SUBJECTS AND METHODS

2.1 Subjects

Subjects are patients that have biliary tract stones treated by laparoscopic choledocholithotomy at the General Surgery Department of Kien Giang General Hospital from 2014 to 2018

2.1.1 Inclusion criteria

Patients with main biliary tract stones include patients with recurrent stones (reoperation) diagnosed surely and determined location of stones, size of stones and bile ducts by pre-operative computerized tomography Select the following cases:

+ Simple choledocholithiasis: Choose cases with diameter of choledocholithiasis ≥ 20mm or preoperative ERCP failed

+ Cholecysto-choledocholithiasis

+ Choledocholithiasis combines with intrahepatic stones with or without choledolithiasis

2.1.2 Exclusion criteria

- Age < 18 years old

- Diameter of choledocholithiasis determined on CT < 10mm

- Patient have stones in biliary tract cyst

- Simple intrahepatic stones, no choledocholithiasis

- Contraindication of laparoscopic surgery: coronary artery disease, respiratory failure

n ≥ Z2 (1- α/2)p(1-p)/d2 Confidence interval: 95%, Z = 1,96; d = 0,05

p: Success rate of laparoscopic choledocholithotomy 86,5 - 97,7% [10], [14], [67] We choose p = 0,95 (95%)

The number of patients needed to research at least 73

2.2.4 Technique

- Endotracheal anesthesia Patient supine

- Surgeon and camera man standing on the left, assistants standing on the right

Main steps of laparoscopic surgery:

Step 1: Đặt trocar, Air insufflation

Step 2: Investigate the abdominal cavity

Step 3: Exposure and choledochotomy

Step 4: Removing stones

Step 5: Cholangioscopy

Step 6: Cholecystectomy when indicated

Step 7: Place the Kehr tube

Step 8: Hoàn thành cuộc mổ

2.2.6 Researching on indications

+ Ratio of first surgery or biliary tract stones reoperation

+ Ratio of simple choledocholithiasis

+ Ratio of cholecysto-choledocholithiasis

+ Ratio of choledocholithiasis combines with intrahepatic stones + Ratio of patients ≥ 70 and < 70 years old

+ Ratio of preoperative ERCP failed

Comparison between groups on operative time, flatus time, pain relief, hospital stay time and rate of stone clearance

2.2.7 Intraoperative researching: technique of laparosopic surgery

* Patient posture and trocar placement

* Investigate the abdominal cavity:

+ Diameter of CBD

+ Choledocholithiasis or no choledocholithiasis

+ Investigate gall bladder with inflamation, stones

+ Investigate liver stalk with or without adhesion

+ In the case of abdominal surgical scar: not adhesion, little adhesion, a lot of adhesion in abdominal wall, the liver stalk

*Choledochotomy technique: vertical or horizontal incision, location

*Method to remove stones

Assess advantages, disadvantages of technique and stone extraction method

*Check stone clearance and clean of biliary tract

- Cholangioscopy with or withou retained stone?Management, result?

* Biliary tract drainage: T-tube drainage or closure

*Intraoperative accidences: Bleeding, duodenal perforation

*Converting to open: ratio, causes?

*Calculating operative time

2.2.8 Researching surgical results

+ Success ratio

+ Note time that patient can eat, drink, flatus

+ Note time using pain relief drug

+ Note postoperative dysfunction

+ Postoperative complications

+ Hospital stay time

+ Result of postoperative ultrasound, cholangiography via T-tube + Location of residual stones

+ Managing residual stones: Lithotripy, ERCP, observation

+ Ratio of stone clearance Determining stone clearance base on 3 following factors that all are clear:

 Cholangioscopy

 Postoperative ultrasound without stones

 Cholangiography via T-tube without stones

+ Recurrence, recurrence time?

* Assess result of laparoscopic surgery:

- Postoperative early results

+ Good: The patient was examined postoperative biliary tract, which showed that stones was cleaned

+ Medium: The patient is stable, the biliary tract remains stones Removing stones through Kehr tunnel or ERCP are required There are complications (except surgical infections) but medical treatment

is stable, not sequelae

+ Bad: Occurrence of complications must reoperate or die

- Long term result

+ Good: A healthy patient returns to his previous job Ultrasound or computerized tomography does not recur stones

+ Medium: patients does not returns to his previous job Ultrasound

or computerized tomography has recurrence but not requiring reoperation or only ERCP required

+ Bad: Ultrasound or computerized tomography has recurrence requiring reoperation, death due to disease of biliary tract

2.2.9 Methods of processing and analyzing data

The data is collected by sample records, then the variables are encrypted and entered into the computer All statistical analyses were performed using SPSS 20.0 software

Chapter 3 RESULTS 3.1 Common characteristics

3.1.1 Age and gender

- Total number of patients: 103 cases

- Gender: Male 35/103 patients; Female 68/103 patients ;

- Male / female ratio: 2/1

- The average age : 56,2 ± 14,9 (24 - 89) years old

3.1.3 History

History of abdominal surgery: 41/103 cases, equal to 39,8%

3.2 Indication, techniqual characteristics, results of laparoscopy

103 cases were operated, 3 cases converting to open surgery

So total of laparosopic surgery were 100 cases

Table 3.18 Methods of laparosopic surgery

Surgical methods n =100 Ratio (%)

Choledocholithotomy, T- tube drainage 54/100 54,0 Choledocholithotomy, cholecystectomy, T-

3.2.1 Indications of laparoscopic surgery

- Reoperative ratio: 36% cases, first surgery 64% cases

- Patients > 70 years old: 20% cases, < 70 years old: 80% cases

- Pre-operative ERCP to remove stones failed: 7/100(7%) cases

- Location of stones:

+ Simple choledocholithiasis: 25/100(25%) cases + Cholecysto-choledocholithiasis: 22/100(22%) cases

+ Choledocholithiasis, intrahepatic stones: 53/100(53%) cases

- Extrahepatic stones: 47/100(47%) cases

- Choledocholithiasis, intrahepatic stones: 53/100(53%) cases

3.2.2 Techniqual characteristics of laparoscopic surgery

100% Patient supine, surgeon standing on the left

100% Placing 4 trocars

100% Vertical choledochotomy

100% T- tube drainage

100% Removing stones by instruments and washing

100% Having intraoperative cholangioscopy

100% Interrupted suture to close CBD, using Viryl 3.0

3.2.3 Results of laparoscopic surgery

3.2.3.1 Cholangioscopy in laparoscopic surgery

*Determining retained stones, stone clearance:

Bảng 3.19 Results of cholangioscopy in laparoscopic surgery

Intraoperative cholangioscopy Number (n=100) Ratio (%)

- Comparing the ratio of residual stone after removing stones with tools in the first surgical group (54.7%) was lower than reoperative group (69.4%) but the difference was not statistically significant with

p = 0.533 according to Chi squared test

- Comparison of the rate of residual stone detected by cholangioscopy in intrahepatic stone group (84.5%) was higher than extrahepatic stones group (25.5%) and the difference was statistically significant with p = 0,000

* Managing retained stones were detected by cholangioscopy:

32/57(56,1%) cases have intraoperative electric hydraulic lithotripsy