Comparison between Comprehensive Complication Index (CCI®) and Clavien-Dindo Classification for laparoscopic single-stage treatment of choledocholithiasis with concomitant cholelithiasis

Laparoscopic common bile duct exploration for choledocholithiasis on an emergency setting

INTRODUCTION

Choledocholithiasis is a common clinical condition that may present with severe complications such as acute cholecystitis or cholangitis, requiring treatment on an emergency setting. This situation is frequently managed following an endoscopic approach by ERCP. However, access to emergent endoscopic biliary decompression is lacking in most centers. In addition, experience in laparoscopic common bile duct exploration (LCBDE) in elective patients is increasing revealing good outcomes. This study analyzes the outcomes of LCBDE management of choledocholithiasis performed on an emergency setting (ELCBDE).

MATERIALS AND METHODS

We performed a descriptive, prospective, single-center study of patients undergoing ELCBDE from January 2020 to December 2023. Demographic, clinical, and surgical variables were recorded. Postoperative complications (Dindo-Clavien), the success of stone clearance, and the occurrence of bile leaks (ISGLS) were also documented. Recurrence of choledocholithiasis and the association between severe complications and Charlson Comorbidity Index (CCI) were analyzed.

RESULTS

A total of 31 patients were included. Median age was of 78 years. The transductal (TD) approach was employed in all cases without conversion to open surgery. The median CCI was 4. Intraoperative cholangiography was performed in 19.4% of cases and over 4 stones were extracted in 35.5% of the patients. Primary closure of the choledochotomy was achieved in 93.5% of patients. Severe complications (DindoClavien ≥ 3) occurred in 6.5% of patients. There were no reintervention or technique related deaths. Stone recurrence was not detected. The mean hospital stay was 4 days. Neither CCI nor advanced age was significantly associated with severe complications development (p > 0.05).

CONCLUSIONS

ELCBDE plus LC is an effective and safe procedure associated with low morbidity and mortality rates. Patients with a high CCI or advanced age should not be discarded for emergent laparoscopic approach. Our results support the choice of ELCBDE as a primary option in the emergency management of choledocholithiasis.

Reconstructive interventions on bile ducts in patients with benign obstructive jaundice

Aim. To evaluate immediate and long-term results of surgical reconstruction of the biliary system in various types of benign obstructive jaundice.

Materials and methods. The study enrolled 110 patients with choledocholithiasis, iatrogenic biliary strictures, common bile duct strictures, as well as strictures of biliodigestive and biliobiliary anastomoses. Patients were divided into 3 groups. Group 1 included 43 patients with multiple choledocholithiasis and bile duct dilatation >15 mm. Group 2 enrolled 35 patients with multiple choledocholithiasis and hepaticolithiasis who were intraoperatively diagnosed with stricture, injury, or pressure ulcers of the common bile duct wall. Group 3 included 32 patients with cicatricial and iatrogenic biliary strictures. The immediate and long-term results of surgical treatment were compared.

Results. In group 1, the survival rate comprised 89.4%, the average duration of surgery amounted to 137 minutes, complications involved wound infection, bile leakage, bile peritonitis. In group 2, the survival rate accounted for 91.4%, the average duration of surgery comprised 192 minutes; strictures of biliodigestive anastomosis were detected in the remote period, and reconstructive surgeries were performed. Group 3 revealed the survival rate of 100%, the average duration of surgery of 215 minutes, and no complications in the long term.

Conclusion. The diameter of the common bile duct, its wall changes, size of gallstones, signs of cholangitis, patency of the bile papilla, and localization of biliary stricture determine the surgical tactics, when performing biliary reconstruction in patients with non-cancerous obstructive jaundice. In case minimally invasive surgery is found impossible under conditions of multiple choledocholithiasis, common bile duct diameter >15 mm, and preservation of its wall, choledocholithotomy with Kerr drainage is considered to be optimal. In case of damage to the CBD wall and patency of the bile papilla, preference shall be given to hepaticoenterostomy. Bile duct reconstruction with stent drainage is indicated for treatment of cicatricial and iatrogenic biliary strictures.

Results during the learning curve in the laparoscopic common bile duct exploration for choledocolithiasis

OBJECTIVES

To analyze the results obtained in terms of efficacy and safety during the learning curve of a surgical team in the technique of laparoscopic common bile duct exploration with cholecystectomy (LCBDE+LC) using choledochoscopy for the treatment of patients with cholelithiasis and choledocolithiasis or common bile duct stones (CBDS) (CDL).

METHODS

Single-center prospective analysis of patients treated with LCBDE+LC during the first 4 years of implementation of the technique. A descriptive and comparative analysis was carried out between groups according to the transcystic (TCi) or transcolecocal (TCo) approach, and also evolutionary by periods. The effectiveness of the technique was evaluated using the variable success rate and safety through the analysis of the overall complication rate and the bile leak rate as the most frequent adverse effect.

RESULTS

A total of 78 patients were analyzed. The most frequent approach was TCo (62%). The overall success rate was 92%. The TCi group had a shorter operating time, a lower overall complications rate and a shorter hospital stay. The TCo approach was related to a higher rate of clinically relevant bile leak (8%). Complex cases increased significantly during the learning curve without effect on the overall results.

CONCLUSIONS

LCBDE+LC is an effective and safe technique during the learning curve. Its results are comparable to those published by more experienced groups and do not present significant differences related to the evolution during learning period.

Efficacy and safety of double endoscopy combined with exploration in the treatment of elderly patients with cholecystolithiasis complicated with choledocholithiasis

OBJECTIVE

To investigate the efficacy and safety of laparoscopy combined with choledochoscopy in the treatment of elderly patients with cholecystolithiasis complicated with choledocholithiasis.

METHODS

A retrospective analysis of 114 patients admitted to our hospital from January 2020 to January 2023 was conducted. These patients underwent laparoscopic cholecystectomy combined with choledocholithiasis and were divided into an elderly group (≥ 60 years old) of 63 cases and a young and middle-aged group (< 60 years old) of 51 cases according to age. The efficacy and safety indicators of the two groups of patients were observed, and complications were followed up by telephone within 6 months after surgery. The follow-up deadline was June 2023.

RESULTS

Among the eligible patients (53 men, 61 women, average age 57 years), all were successfully operated, and 1 case was converted to laparotomy. The elderly and young and middle-aged groups were compared concerning hospitalisation time, bowel sound recovery time, and total postoperative complications, and the differences were statistically significant (P-values were 0.009, 0.006, and 0.039). However, there was no statistically significant difference between the two groups of patients in terms of hospitalisation costs, intraoperative blood loss, operation time, drainage tube removal time, conversion to laparotomy rate, and stone clearance rate (P-values > 0 0.05).

CONCLUSION

Strict adherence to surgical standards and enhanced postoperative care resulted in similar efficacy and safety results for double endoscopy combined with the exploration of treatment for elderly and young patients with cholecystolithiasis and choledocholithiasis.