Textbook outcome – Measure efficacy and safety of common bile duct stone (CBDS) removal during cholecystectomy

Abstract Introduction Methods to clear CBDS carries varying risk of adverse effects while leaving them in situ can lead to complications. Thus, the modality of choice reasonably affects the assessment of whether an attempted removal of asymptomatic CBDS is feasible and adequate. Method The study was based on the national Swedish Register for Gallstone Surgery and ERCP (GallRiks) with validated prospectively assembled data for 90% of all cholecystectomies and ERCP procedures from 2009 to 2023. Odds ratios for failing textbook outcome for methods of clearing CBDS was estimated. Leaving CBDS in situ was reference. Textbook outcome was defined as cholecystectomy and CBDS clearance laparoscopically completed in one session without immediate or 30-day surgical complications, readmissions, reinterventions or prolonged postoperative hospitalization beyond three days. Result For CBDS during cholecystectomy, intraoperative ERCP (IOERCP) and trans cystic extraction had unadjusted OR 0.7 (95%CI 0.63-0.77) and 0.63 (95% CI 0.55-0.71) respectively to fail textbook outcome compared to CBDS left in situ. Flushing and manipulating the stone had OR 0.5 (95% CI 0.44-0.57). For asymptomatic stones smaller than 4mm only from flushing manipulating was beneficial with OR 0.73( 0.59-0.90). Discussion Using textbook outcome to report successful CBDS clearance at cholecystectomy this study finds the greatest benefit for the flush/manipulate group which was the only one beneficial to the small asymptomatic stones compared to leaving them in situ. Balancing safety and efficacy of available methods for clearing them is thus paramount. Small asymptomatic stones do not seem to clearly benefit from more invasive removal attempts than flushing and manipulating with cholangiocatheter.