**2. Obstructive jaundice and treatment modalities**

Obstructive jaundice is not an uncommon clinical entity caused by different benign or malignant diseases. The most common benign pathology of the bile ducts worldwide is choledocholithiasis defined as the presence of stones in the common bile duct (CBD). According to the different authors, CBD stones are present in 10–25% of all patients undergoing cholecystectomy for stones in the gallbladder and in about 10% of patients who undergo cholecystectomy for symptomatic cholelithiasis (gallstones in the gallbladder). On the other hand, 95% of patients with confirmed choledocholithiasis have stones in the gallbladder too. CBD stones can remain silent for a long time, but they can also be associated with recurrent upper abdominal pains, intermittent jaundice, cholangitis, and recurrent pancreatitis. According to the recommendations, choledocholithiasis (CCL) should be confirmed in the perioperative period because of its direct relation with the bile leaks in the early postoperative period of cholecystectomy [3–6].

Chronic pancreatitis can also impede the excretion of bile into the duodenum. The malignant causes may be a biliary tumor, pancreatic cancer, ampulla of Vater, or duodenal tumor.

The iatrogenic cause (e.g., misplaced clip after laparoscopic cholecystectomy) can also be an explanation for extrahepatic bile duct obstruction at the time of the widely accepted laparoscopic surgical approach [7–10].

In most benign biliary diseases, jaundice is intermittent, not long-lasting, and provoked by incomplete bile duct obstruction. Only a few benign diseases (e.g., primary sclerosing cholangitis) result in persistent obstructive jaundice, in biliary cirrhosis and portal hypertension, and most cases are related to stone obstruction complicated or not with cholangitis [11, 12]. The benign pathology associated with jaundice has usually total bilirubin level less than 100 μmol/l and that condition is well tolerated by the patients. In contrast, the malignant obstructive jaundice is usually a prolonged process with total bilirubin level greater than 100 μmol/l. This devastating disorder is generally observed in older adults with compromised immune system, chronic organ dysfunction or other health problems. The malignant biliary obstruction is rarely associated with acute cholangitis at the time of clinical diagnosis [13].

All patients with obstructive jaundice usually present a different degree of icterus (depending on the level of hyperbilirubinemia), dark urine, pale stools, and itchy skin (pruritus). Right hypochondrial abdominal pain, radiating to the back or right shoulder is very suspicious for acute cholecystitis (Ac) or AOC and is rarely associated with the malignant cause of the biliary obstruction.

AOC is an acute inflammation of the bile ducts caused by bacterial infection. The most common organisms implicated are coliform organisms. These include *Escherichia coli* (25%-50%), *Klebsiella* species (10%-20%) and *Enterobacter* species (5%-10%)*.*

The diagnosis of obstructive jaundice is based on the clinical signs, laboratory data, and imaging findings.

AOC is first described by Charcot in 1877. Charcot's triad (fever, right upper quadrant pain, and jaundice) actually occurs in only up to 75% of patients with acute cholangitis (biliary infection) and carries a poor sensitivity [21.2–26.4%]. Association of these clinical signs with altered mental status (confusion) and signs of shock (hypotension and tachycardia) known as Reynolds pentad is suggestive of suppurative cholangitis, which is reported in up to 7.7% of all jaundiced patients [14].

#### *Laparoscopic Approach in the Case of Biliary Obstruction: Choledocholithiasis DOI: http://dx.doi.org/10.5772/intechopen.106042*

The diagnosis of acute cholangitis is essential because this complication of biliary obstruction can rapidly progress to a severe form accompanied by organ dysfunction, caused by systemic inflammatory response syndrome (SIRS) and/or sepsis. Prompt diagnosis and thorough assessment of the patient are necessary for appropriate management, including intensive care with organ support, and urgent biliary drainage in addition to early medical treatment.

Usually, biliary infection alone does not cause clinical cholangitis unless biliary obstruction raises the intraductal pressure in the bile duct to levels high enough to cause cholangiovenous or cholangiolymphatic reflux. This can lead to the destruction of the barrier between the capillary bile duct and the liver sinusoid, resulting in sepsis, septic shock, and multiple organ dysfunction due to bacteria entering the bloodstream [15]. Thus, acute cholangitis progresses from local biliary infection to the systemic inflammatory response syndrome (SIRS), and the advanced stage leads to sepsis with or without organ dysfunction. If the obstruction cannot be removed in time, it often rapidly develops into AOC, which is life-threatening. Therefore, early diagnosis, infection control, and removal of bile duct obstruction are primordial for the primary treatment of this complication. Many less-severe biliary tract infections respond to medical therapy alone. However, early recognition of patients with severe infection and sepsis requiring immediate procedural intervention is crucial, as delayed biliary decompression after failure of medical therapy carries a mortality rate up to 80% [16].

According to the literature in the 1970s, the mortality rate of patients with acute cholangitis was reported to be over 50%, but with advances in intensive care, new antibiotics, and biliary drainage dramatically reduced the mortality rate to less than 7% by the 1980s. However, in the 1990s, the different authors reported mortality rates in severe cases ranged from 11 to 27%, and even now the severe form of acute cholangitis remains a fatal disease (30% mortality) unless appropriate management is instituted promptly [15, 17–19].

The algorithm for the diagnosis and treatment of AOC has been debated for many years. The experts reached at the International Consensus Meeting held in Tokyo 2006 define the new criteria for the diagnosis and differentiation between AOC and Ac, known as the Tokyo guidelines. These criteria are based on the history of biliary disease, the clinical manifestations, laboratory data that indicate the presence of inflammation and cholestasis (WBC, CRP, bilirubin, AST, ALT, ALP, and GGT), and imaging findings that indicate biliary obstruction and duct dilation confirmed by MRCP (magnetic resonance cholangiopancreatography), US, CT, and ERCP. Later, the Tokyo Guidelines 2018 defined empiric therapy for acute cholangitis and cholecystitis [20, 21]. According to the Tokyo Consensus Meeting, the severity of acute cholangitis should be divided into three grades—mild (grade I), moderate (grade II), and severe (grade III) based on the response to initial medical treatment and the existence of organ dysfunction. These guidelines try to delineate more precise diagnostic and treatment algorithms for patients with complicated obstructive jaundice [21].

Obstructive jaundice has devastating consequences on every body system, which carries an increased risk to the patient before the intervention and risk of postoperative complications. Even though the early diagnosis requires prompt medical treatment and surgical drainage of the CBD, there is also a risk to increase procedurerelated complications.

The need for urgent decompression of the bile duct is essential, especially if the patient has an AOC. There are different procedures for decompression of CBD, for

example, ERCP, laparoscopic approach, open surgical access, or percutaneous biliary drainage. Each of these techniques has its benefits and risks, and while making a decision, we should balance the advantages and disadvantages of any of these [7]. But the key question is not only which method for decompression of CBD is better. In each case, we have a specific clinical situation, the technical proficiency of the operator, a particular patient's general condition, and costs. All these factors should be considered in choosing the most appropriate technique and the one that will achieve the best outcome with less risk.

### **2.1 Endoscopic retrograde cholangiopancreatography (ERCP)**

Regarded as the most common intervention today performed for the treatment of obstructive jaundice, this technique was introduced in 1968 into the clinical practice for visualization of bile ducts. The first cannulation of the papilla of Vater and duct visualization, by contrast, was performed by Dr. William S. McCune, an obstetrician. Several years after that Dr. Meinhard Classen in Germany and Keiichi Kawai in Japan simultaneously undertook the first biliary sphincterotomy and ERCP was developed as a therapeutic option for biliary obstruction.

From then on ERCP has become the first-line modality for the diagnosis and treatment of pancreatobiliary diseases (mainly biliary obstruction and bile duct stones). Today ERCP can be performed before, during, or after cholecystectomy, and may also be combined with either sphincterotomy (transection) or sphincteroplasty (papillary dilatation) for stone retrieval from the CBD or stent placement.

The indication for ERCP is a distal CBD obstruction with CBD dilation, confirmed by MRCP.

The procedure is usually performed under conscious sedation. Biliary decompression by ERCP, even essential in the management of obstructive jaundice, may provoke also acute obstructive cholangitis (AOC), one of the procedure-related complications related to the ERCP [22].

The incidence of post-ERCP cholangitis ranges from 0.4 to 10%, carrying a mortality rate of 0.1%, [23–25]. If there is a failure of ERCP for biliary stone removal the risk for postoperative AOC is multiplied. However, endoscopic sphincterotomy for bile duct stones has a disappointing 8–10% rate of long-term biliary complications, including recurrent or residual ductal stones, cholangitis, stenosis of the papilla, and biliary pancreatitis [26]. Goodall and Macadam [27] referred to a 28% rate of late symptoms related to low-grade cholangitis following papillosphincterotomy.

Although ERCP has increasingly become a very popular procedure, post-ERCP complication rates may reach 9.7%, with a mortality rate of 0.7%. The four most common complications are [23, 28–30]:

### 1.Post-ERCP pancreatitis.

2.Biliary or duodenal perforation.


*Laparoscopic Approach in the Case of Biliary Obstruction: Choledocholithiasis DOI: http://dx.doi.org/10.5772/intechopen.106042*

### **2.2 Percutaneous transhepatic biliary drainage (PTBD)**

This procedure is one of the possibilities for the fast resolution of obstructive jaundice in experienced hands. It can be performed by a radiologist using local anesthesia. Started as a percutaneous cholangiography, the first PTBD was reported by Kaplan, who put it in place in 1961. Later the two-step puncture method of PTBD was introduced in clinical practice by Takada et al.

The indication for PTB is intrahepatic bile duct dilation, confirmed by the US. PTBD was performed under ultrasound (US) and fluoroscopy guidance with localization of the biliary tree and selection of the entry site. The access site can be through the right or left lobe of the liver. Generally, a 21-gauge needle was first introduced under the US guidance into the chosen bile duct. Through the needle, a 0.018″ guidewire is put in place and the needle is exchanged for a 5-Fr catheter for cholangiography. After performing cholangiography and verification of bile duct anatomy, the catheter is then withdrawn and 8-Fr multisidehole catheter is advanced and positioned over the guidewire (Boston Scientific, Boston, USA). The catheter was then secured to the skin and connected to a bag for 48 h. If the tip of the biliary catheter is positioned in the duodenum, the biliary drainage is named internal. If the catheter's tip is above the biliary obstruction, the drainage is external [31].

The complications of PTBD are as follows:


#### **2.3 Laparoscopic common bile duct exploration**

After the first open cholecystectomy performed by Langenbuch in 1882, the first successful open CBD exploration (OCBDE) was employed by Courvoisier, in 1890. A century later, in 1985, the first laparoscopic cholecystectomy (LC) was introduced into clinical practice and soon became the standard of care [32]. The first reports about LCBDE are in the early 1990s, when Traverso, who had made some early LCBDE studies, recommended one-step LCBDE to treat CBD stones [3, 33, 34]. According to Traverso and other authors, it is accepted that ERCP may lead to disruption of the sphincter of Oddi and induce several severe postoperative complications, such as pancreatitis, bleeding, and perforation. That is why they seek alternative resolutions to this problem [4–6, 35].

From then on LCBDE has been employed effectively in thousands of cases, although a relatively small percentage of the biliary tract surgeons practicing this technique today. The reasons for the reluctance to perform LCBDE are numerous (e.g., technical difficulties, prolonged operative time, need for general anesthesia, and need more advanced laparoscopic skills). Although the routine adoption of LCBDE associated with cholecystectomy as a one-stage procedure has been promoted by the constant improvement in techniques and expertise of surgeons who are increasingly confident with laparoscopic hepato-biliary surgery.

It is important to take into account, however, that prior to the introduction of LC, surgeons were apt to clear the CBD system in 90% of cases where they attempted CBD exploration [36, 37]. Since the advent of LC, most surgeons have revoked the opening and cleaning of CBD and returning the biliary tract to its normal healthy status without leaving residual ductal calculi. Instead, they have relied more on alternative and additional interventional methods (e.g., ERCP) to handle these problems [38]. Although this endoscopic technique is certainly useful in managing complicated biliary tract problems, it is not without cost, morbidity, mortality, and significant lifestyle disruption. Even in the best hands, ERCP carried with it morbidity rates as high as 15% and mortality rates of 1%.

At present, the minimally invasive treatment techniques for CBD stones are LCBDE plus laparoscopic cholecystectomy (LCBDE+LC) as the one-stage procedure or endoscopic retrograde cholangiopancreatography (ERCP) plus laparoscopic cholecystectomy (ERCP+LC) as a two-stage procedure [39, 40]. The preferred succession is preoperative ERCP+LC (pre-ERCP+LC), which is recommended by the European Association for the study of the liver [41], however, no clear statements have been published regarding the best treatment for CCL. We should take into account that ERCP may cause destruction of the sphincter of Oddi, resulting in reflux of duodenal juice, leading to recurrence of CBD stones, episodes of cholangitis, and even carcinoma. In addition to the ERCP's complications, such as pancreatitis, bleeding, and perforation, the drawbacks of ERCP are also two-stage procedure, and the patients need to have two different anesthesiologic sessions.

As a one-stage procedure, the important advantages of LCBDE+LC are preserving the function of the sphincter of Oddi with a reduction of the overall hospital stay and cost [39, 42].

The optimal strategies for the management of CBD stones remain controversial and further studies on this topic are recommended according to the literature.

Considering a meta-analysis published in 2018 comparing the outcomes of LCBDE with the pre-ERCP+LC, the authors reported that the pre-ERCP+LC group had a higher CBD stone clearance rate than the LCBDE+LC group (OR 1.63; 95% CI 1.16–2.28; p = 0.005). The study revealed that the pre-ERCP+LC had a lower postoperative bile leakage rate than the LCBDE+LC group (OR 4.08; 95% CI 2.08–7.98; p < 0.0001) and the overall morbidity and mortality was not significantly different between the two groups. Although the overall hospital stay was significantly shorter in the LCBDE+LC group (mean difference [MD], − 2.46 days; 95% CI − 3.67 to −1.24; p < 0.0001), the rate of postoperative pancreatitis was significantly higher in the pre-ERCP+LC than LCBDE+LC group (OR 0.18; 95% CI 0.06–0.50; p = 0.001) [43].

Three prospective randomized studies were published related to the recurrence and residual stones, comparing two techniques LCBDE with ERCP. The authors reported a lower recurrence rate of the LCBDE+LC approach [44–46].

According to the literature, LCBDE is a safe, effective, and feasible technique that can be applied in the treatment of cholelithiasis even to patients with nondilated CBD (e.g., less than 10 mm in diameter). Although, considering that there are certain difficulties with the operative technique (e.g., cystic duct cannulation or stone extraction) some authors still recommended the application of LCBDE into the clinical practice. In this study including 47 patients with nondilated CBD, the clearance rate of bile duct stones after LCBDE was 100%, with no complications and no mortality occurred [47].

LCBDE has been used worldwide for nearly 30 years, and its advantages are valued by surgeons for a long time. On the other hand, many fragile elderly patients with AOC frequently present systemic concomitant diseases needing emergency

### *Laparoscopic Approach in the Case of Biliary Obstruction: Choledocholithiasis DOI: http://dx.doi.org/10.5772/intechopen.106042*

admission, diagnosis, and operation. The operation for AOC in the elderly should be simple, quick, and effective because the basic health status of elderly patients is usually fragile. Trying to find a place for LCBDE in the treatment of complicated AOC for elderly patients, there was a study published in 2019 [48]. Enrolling 98 patients (>65 years), divided into three groups (ASA II, III, and IV) according to their general status, the authors found out that LCBDE was a safe, effective, and feasible emergency procedure for treating complicated AC in elderly patients. They noted that all the patients recovered successfully with no mortality, and no residual biliary stones detected by cholangiography before discharge from the hospital. Only three patients had a biliary leak postoperatively that gradually decreased and four patients had a recurrence of CBD stones one year later.

LCBDE can be accomplished with a variety of techniques. There are two basic techniques that give access to the CBD, transcystic approach (via the cystic duct) and transductal approach (via choledochotomy). The benefits of the transcystic method are confirmed and related to minimal morbidity, no T-tube left in the CBD, and a rapid return to normal activity in most cases. The transductal approach is more complicated, but useful in cases where extrahepatic large stones or intrahepatic stones are expected. This approach can be utilized if the cystic duct is too small in size or a very long course precluding its use. The latter approach, however, requires the acquisition of laparoscopic suturing and knot-tying skills not necessary in the transcystic technique [49, 50].

In the case of primary hepatolithiasis, which is a prevailing biliary disorder in eastern and southeastern Asian populations, some authors proposed stone extraction or using cholangioscopy through the left hepatic duct orifice. The reason for that is the left intrahepatic stones account for the majority of cases [51].

According to the medical literature, endoscopic and open surgical interventions of CBD are widely implemented as the standard practice in common bile duct exploration. However, the laparoscopic approach has been also reported to have comparative, even superior outcomes in this concept. This has created an ongoing debate about the ideal approach to adopt in practice.

In 2021, a systematic review of evidence was published on the outcomes of laparoscopic exploration of the common bile duct through transductal and transcystic approaches over the last 10 years. Including 36 relevant papers, 3 meta-analyses, 8 randomized controlled trials, 18 retrospective, 4 prospective studies, and 3 review articles, the authors concluded that LCBDE compared to OCBDE, had significantly lower mortality (0.25% vs. 5.5%), less surgical site infection (1.2% vs. 10%), and overall morbidity (3.7% vs. 22%). The vast majority of the reviewed studies reported that LCBDE (through transductal and transcystic approach) was associated with CBD clearance rates greater than 84% [52].

Comparing the transcystic to the transductal approaches in LCBDE, most studies were in favor of the transcystic route. This can be explained by the lower incidence of associated bile leak (1.4% vs. 6.9%), and shorter duration of hospital stay (4.9 vs. 7.3 days). In addition, one meta-analysis revealed that the mean duration of the operative time was statistically in favor of the transcystic approach (113.8 vs. 126.3 minutes) [52].

The overall conclusion from this systematic review indicates that LCBDE, through transductal or transcystic routes, is safe when performed by an experienced surgeon and on clinically fit selected patients. In addition, there is statistically less overall morbidity and a shorter duration of hospital stay after LCBDE when compared to OCBDE. The conclusion of this review disclosed more successful clinical results of LCBDE in CBD clearance when compared with OCBDE and ERCP [52].

The presumption that LCBDE may have long-term cost-effective benefits may be explained by the fact that LCBDE is performed as single-stage procedure during laparoscopic cholecystectomy, has a shorter length of hospital stay, and decreased utilization of other resources like endoscopy and radiology. On the other hand, the bile leak rates seem to be comparable between LCBDE and OCBDE, and the associated mortality with LCBDE is comparable to the reports associated with OCBDE and ERCP. Also, according to this study laparoscopic transcystic route seems to have a superior outcome when compared to the laparoscopic transductal route regarding bile leak rates [52].

In 2013, the results from 16 randomized clinical trials were published including 1758 participants and comparing the results from OCBDE versus LCBDE versus ERCP for CBD stones. The analysis suggests OCBDE appears to be as safe as ERCP and may even be more successful than the endoscopic technique in clearing the duct stones. LCBDE appears to be as safe as and as effective as the endoscopic technique [53].

According to the opinion of many authors, the overall conclusion was that each of these techniques has its risks and benefits, more reliable studies are needed and the choice depends on the patient's condition and the surgeon's expertise and confidence.
