Rendezvous Technique for Cholecystocholedochal Lithiasis in Octogenarians: Is It as Effective as in Younger Patients,or Should Endoscopic Sphincterotomy Followed by Laparoscopic Cholecystectomy Be Preferred?

Introduction

The treatment of cholecystocholedocal lithiasis (CCL) requires cholecystectomy and common bile duct (CBD) clearance. ¹ These can be done by several techniques encompassing surgery alone or a combination of surgery and endoscopy. The latter can be performed as a two-stage approach by a sequential treatment, including endoscopic retrograde cholangiography (ERC) and sphincterotomy (ST) followed by delayed cholecystectomy (LC)^2–6 (or vice versa), ⁷ or simultaneously, according to the so-called rendezvous technique (RVT). This last option implies performing LC, ERC, and ST during the same procedure.^8–11

Since the 1980s, the two-stage sequential treatment (TSST) has gained widespread usage because of the lower morbidity rate^12,13 compared with open surgery, although the latter was reported to achieve higher rates of CBD clearance. ¹⁴ We have proven that TSST is safe and effective not only in young patients but also in octogenarians. ¹⁵ By the 1990s, the totally laparoscopic treatment of both CBD stones (CBDS) and gallbladder stones was shown to be superior to TSST in terms of morbidity, mortality, CBD clearance, and costs,^16–19 although it is technically a more demanding procedure, requiring specific training and costly, dedicated instruments. More recently, RVT was introduced and has gained popularity as it is reported to be safe and effective in the general population.^8,9,20 Unfortunately, the literature is lacking regarding the use of RVT in the very elderly.

In the present study we compared early and late results of RVT between patients younger and older than 80 years of age. Moreover, in order to identify the best approach to the very old patients, the outcome of the elderly group was compared with that achieved with TSST, in a similar population of octogenarians.

Subjects and Methods

From April 2005 until December 2008, 136 consecutive patients with biliary tract stone disease underwent RVT at the Department of Surgery of the Hospital of Guastalla, Guastalla, Italy. Upon admission all patients underwent clinical examination and laboratory tests, including liver function tests (LFTs) and abdominal ultrasound (US). Those with clinical signs and symptoms of biliary colic or acute cholecystitis, abnormal LFTs, and proven gallstones at US were scheduled for an LC and intraoperative cholangiogram (IOC). The same procedure was used for those with proven CBDS at US. Conversely, patients admitted with clinical/laboratory signs of obstructive jaundice or with dilated intrahepatic bile ducts at US underwent instead an abdominal computed tomography (CT) scan to rule out other hepatobiliopancreatic diseases. Finally, all cases of new onset of acute pancreatitis (AP) had also a CT scan, and patients diagnosed with mild biliary AP were scheduled for RVT (Fig. 1). Magnetic resonance imaging (MRI) was done instead when US was negative despite the persistent clinical/laboratory suspicion of CBDS. In 1 case where MRI was inconclusive, we used endoscopic US to detect CBDS.

OPEN IN VIEWER

FIG. 1.

Patient selection (patients undergoing the rendezvous technique [RVT]). ASA, American Society of Anesthesiologists; BAP, biliary acute pancreatitis; CBDS, common bile duct stones; CT, computed tomography; ENDOUS, endoscopic ultrasound; LFTs, liver function tests; MRI, magnetic resonance imaging. USS, ultrasound scan.

Exclusion criteria from the study were an American Society of Anesthesiologists (ASA) class of 4 and/or planned open surgery. Finally, 131 patients were included (Fig. 1).

All the RVT procedures were done by two surgeons with experience in both laparoscopic surgery and digestive endoscopy. The technique consists of a laparoscopic access first, including the dissection and the opening of the cystic duct, through which a guidewire is passed to the duodenum. Before endoscopy, a soft laparoscopic clamp is used to close the lumen of the first jejunal loop, in order to avoid massive small bowel air insufflation during endoscopy, which may hamper further laparoscopic view. Then a flexible endoscope is advanced to the duodenum, where the guidewire is encountered and caught in order to allow the correct endoscopic cannulation of the papilla major for further contrast dye injection, IOC, and placement of the papillotome for ST. After the endoscopic instruments and the guidewire are withdrawn, a formal LC is performed.

At our institution the policy to perform the ST after IOC is as follows: if the IOC shows no stones, the contrast dye flows smoothly to the duodenum, and preoperative LFTs are improved, no further ST is performed. In the case of actual or previous biliary AP, the ST is instead done even if the IOC findings are normal. If IOC shows no CBDS but there is dye contrast filling of the pancreatic duct, suboptimal duodenography, or persistently altered LFTs, the ST is then performed.

According to our policy, if we fail in obtaining clearance of the CBD through the retrograde approach, we proceed to laparoscopic CBD clearance with a choledochoscope and stone retrieval by a Dormia basket through a 12-mm disposable trocar. If choledochoscopy fails, the procedure is converted, and a classic open CBD exploration is performed through a longitudinal choledochotomy. After CBD clearance by (laparoscopic or open) exploration is achieved, the CBD is closed with interrupted sutures, and a pericholedochal drain is routinely placed.

In 4 patients, RVT was performed together with another procedure: laparoscopic splenectomy for a hematologic disease (n=1), laparoscopic ventral hernia mesh repair (n=1), open groin hernia mesh repair (n=1), and open umbilical hernia mesh repair (n=1). All patients were younger than 80 years of age.

Results

Discussion

Choledochal lithiasis represents a relatively common clinical finding in patients with gallbladder lithiasis and requires both CBD clearance and cholecystectomy. ¹ Recent progress in laparoscopic surgery and endoscopic techniques has rekindled the debate concerning the most appropriate management of this condition.^{12,14,16–25}

The combined TSST approach is still widely used because of its advantages as a mini-invasive approach without the need of specific laparoscopic skills and dedicated instruments.^3–6,26,27 Nevertheless, this technique has showed morbidity, mortality, and costs higher than a totally laparoscopic approach.^16–19 Moreover, it implies two hospital stays or, if a single hospitalization is considered, an optimal integration of endoscopy and surgery schedules.

A totally surgical approach has the main advantage of a single hospital admittance, procedure, and general anesthesia.^14,25,28 A totally laparoscopic management of CCL has proven to be as effective as open surgery with fewer postoperative complications,^{22,24,25,29,30} but, owing to the need of advanced technical skills and dedicated equipment, it has had limited usage up to now.

The RVT, first described by Cavina et al., ⁸ is a single-stage surgical/endoscopic approach to manage CCL that has been reported to be more effective than TSST because it is associated with higher CBD clearance rate, lower morbidity, shorter hospital stay,^9,20 and reduced hospital costs. ²⁰ Such good results may be explained by the specific technique itself because RVT implies the anterograde passage of a guidewire through the cystic duct to the duodenum before the ERC and the ST are performed. This maneuver allows a safer endoscopic cannulation of the papilla major, thus possibly reducing the rate of iatrogenic acute pancreatitis. ¹⁰ Indeed, the downside of the RVT is that it requires specific equipment and dedicated personnel. Because both endoscopy and laparoscopy are performed synchronously, a second operator (endoscopist or endoscopy-trained surgeon) and adequately trained personnel, as well as an appropriately prepared theater (endoscopic and laparoscopic instruments, etc.), are needed at the same time.

Although several authors have reported encouraging results of RVT in the general population,^10,12,14 unfortunately, the literature on RVT in the elderly is lacking. In our experience, RVT in octogenarians was as safe and effective as in younger populations. In the present study, octogenarians showed a higher rate of conversion to laparotomy. Although, theoretically, it may be hypothesized that an older patient may have a more long-lasting CCL, which may somehow increase the difficulty of the procedure (for example, by worsening tissue inflammation/scarring at Calot's triangle, etc.), and age and poorer condition of the patients may also lead the operating surgeon not to postpone conversion, we are instead inclined to believe that a numerical bias (the small size of Group 2) may be responsible for such values.

It is significant that the only failure of RVT in obtaining a complete CBD clearance was recorded in Group 2, where the poor general condition of the patients prevented us from performing a further CBD exploration through a choledochotomy.

Perioperative mortality occurred in an 80-year-old patient as the result of an acute cardiovascular event. Nevertheless, a similar rate of perioperative complications in Group 1 and Group 2 seems to confirm the safety of RVT in octogenarians.

The hospital stay was longer among octogenarians. We could explain that as the result of several aspects. First, the octogenarians had more comorbidities; hence we adopted a more cautious attitude with regard to early discharge. Second, all of them were discharged home, and some had social issues that had to be addressed.

Further endoscopy was needed in 2 cases. In the 60 year-old patient whose jaundice persisted up to 13 days postoperatively requiring further biliary stenting—despite a good CBD clearance during the intraoperative ERC—we retrospectively argue that a preoperatively undiagnosed biliary stricture was already present at surgery rather than developed postoperatively. The second was the case of the 85-year-old whose RVT and CBD clearance failed (see above).

No late surgery/endoscopy-related deaths occurred in either group, although, interestingly, late surgery-related complications were recorded only among patients from Group 1. Possibly, a more active lifestyle of younger patients may be supposed to play a role in late morbidity (at least in the occurrence of incisional hernias), but we are instead inclined to believe that the small Group 2 population biased that value.

Cost comparison showed no difference between octogenarians and younger patients, as the only relevant cost difference between the two groups concerned the hospital stay, which was longer for the older patients.

In order to show the real safety and effectiveness of RVT in the elderly, we also compared the results of Group 2 with those of octogenarians undergoing treatment of cholecystocholedochal disease by TSST.

Small population size, retrospective analysis, and comparison of two different approaches in two different environments are definitely potential biases of this study.

Patients from Group 2 showed a significant higher percentage ASA 3 score; moreover, none of those from Group 3 had biliary AP. In the light of such a difference, it is in our opinion remarkable that the results in Groups 2 and 3 were in the end similar. In fact, conversion rates were almost the same in the two groups, as well as the success rate, and the total operative time (including that needed to perform ERC/ST in Group 3) did not differ between the two groups.

Both perioperative and late morbidity rates were also similar in the two groups; however, biliary leak occurred only in patients undergoing RVT. Clearly, our series cannot exhaustively explain why such a complication occurred in the RVT and not in the TSST group. To our knowledge, only 1 case of postoperative biliary leak after RVT has been reported in the literature and was due to a retroperitoneal perforation during ST. ⁹

Octogenarians undergoing RVT remained in the hospital longer than those having TSST. That result differs from other series—all including patients up to 75 years of age^9,20—where RVT carried a shorter postoperative hospital stay than TSST. We may argue that the higher ASA 3 score rate and preoperative diagnosis of biliary AP in Group 2 may account for such a difference with the literature, but instead we believe that the occurrence of two long-lasting postoperative complications (biliary leak) may partially explain this vlaue in a relatively small-sized group.

It is interestingly that such a difference observed in postoperative (postsurgical) stay virtually disappeared when we consider the “total” hospital stay, including, in Group 3, the delay between ERCP/ST and LC. In fact, a median 5-day delay between ERC and LC has been recorded in Group 3. As described above, theater schedules, patients' general conditions requiring further anesthetic assessment, and need for further diagnostic tests accounted for such a long delay. Unfortunately, our hospital policy did not provide for a temporary transfer of the patients to a medical ward while waiting for surgery, where perhaps costs could have been less.

With regard to the cost analysis, in contrast with recent literature in the general population, ²⁰ we found that in octogenarians RVT is as expensive as TSST. Both the prolonged operating time (thus increasing the cost of theater utilization) and postoperative stay did not allow the RVT protocol to reduce costs compared with the TSST.

The strength of this article is that it is the first to quantify the results of RVT in octogenarians compared with those obtained in younger patients and with those achieved in the same population by the management of CCL used most frequently nowadays in Europe, the sequential approach by ERC/ST followed by LC.

In conclusion, despite a prolonged hospital stay, our study shows RVT as being as safe and effective in octogenarians affected by CCL as in younger patients. RVT results are also comparable with those of TSST in octogenarians. However, the retrospective nature of the study, a small population size, and short follow-up do not allow for definitive conclusions. Only a prospective randomized trial might trace recommendations for the use of the RVT in the treatment of CCL in octogenarians.