OGBN O06 Sharing Experience of SpyGlass™ Discover and ElectroHydraulic Lithotripsy in Treating Large Bile Duct Stone Through the Trans-Cystic Approach During Laparoscopic Cholecystectomy
Authors: Kouli Tasnim , Gresz Rahel , Khan Jansher , Abdelwaheed Sammeh , Zino Samer 
Published: December 2022

Abstract

Background
The one session management of gallstone (GS) disease associated with bile duct stone (BDS) involves laparoscopic cholecystectomy (LC) with bile duct exploration, which remains the gold standard treatment.
A two-session management with ERCP followed by laparoscopic cholecystectomy, subjects patients to preventable ERCP related risks including perforation, bleeding, pancreatitis, incomplete clearance and repeat tests, especially if patient is fit and keen for cholecystectomy.
Trans-Cystic bile duct exploration (TC-BDE) appears to have less morbidity than Trans-Ductal BDE (TD-BDE). However, large BDS remain the main challenge for the Trans-Cystic (TC) approach, in addition to factors such as, difficult anatomy and proximally located stones.
The development in technology and evolving of spyglass DiscoverTM as 3.6mm choledochoscope with Lockable four-way steering and short tip deflection, that could utilize the electrohydraulic lithotripsy (EHL) has made the TC approach to manage large BDS possible.
The aim of this abstract is to share our experience in the utilisation of the spyglass discovery TM and SG-EHL in management of large BDS using the TC approach.

Methods
Data from laparoscopic cholecystectomies performed by a single surgeon in Tayside NHS between 01/07/2020 and 01/06/2022 has been prospectively collected and evaluated. During the study period, 205 laparoscopic cholecystectomies were performed. From the 205 cases, 118 cases were emergency, and 140 cases involved female patients. Spyglass discover TM and SG-EHL were used in four cases, which will be discussed in the results section.

Results
Cases-1: 39-year-old female with 12mm BDS. Related medical history includes: 1-Right-nephrectomy that was complicated with abdominal abscess 17 years-ago. 2-Failed ERCP that was complicated with necrosis and collection, necessitating an anterior abdominal drain 2 months ago. TC-BDE and clearance was secured with SG-EHL. Abdominal drain for 5-days. Patient discharged home Day 5.
Case-2: A 51-year-old male with alcoholic liver cirrhosis and ascending cholangitis due to 17mm BDS and Gallstone. Trial of TC-BDE that was converted to transductal due to friable inflamed cystic-duct and proximal location of BDS at the confluence. Successful SG-EHL helped in minimizing the size of duct opening. Cystic duct biliary drain, and abdominal drain were placed. CD drain was removed after clear tube cholangiography Day 3. Patient developed bile leak that was treated conservatively, and patient discharged after 15-days, abdominal drain was removed after 8-weeks.
Case-3: 71-year-old female with 15mm BDS was cleared trans-cystically using SG-EHL. No abdominal drains. Patient had raised inflammatory marker post-surgery treated with antibiotics and patient discharged home Day 4.
Case-4: 64-year-old male with12 mm BDS, with previous failed ERCP due to complex duodenal diverticula, TC-BDE and clearance was achieved using SG-EHL LC. Abdominal drain was removed and patient discharge home Day 2.

Conclusions
This study demonstrates that one session management of large BDS associated with GS, is safe and feasible using trans-cystic approach, with the utilization of the TC approach along with the available technology, the SpyGlass™ Discover and electrohydraulic lithotripsy.
Although, the transductal approach might be necessary to ensure bile duct clearance, utilizing SG-EHL might prove beneficial in reducing the size of bile duct opening.
Discussion with the patient and informed consent are essential to ensure Patient-specific therapy. A one session management of GS disease should be offered to patients, if indicated, with available support and expertise. More training opportunities in Laparoscopic bile duct exploration is needed to increase the patient's chance of receiving the gold standard treatment for BDS associated with GS.