Spontaneously removed endobiliary J stent drainage after laparoscopic common bile duct exploration

Temporary CBD Stenting with a Nelaton Tube Is a More Practical and Safer Option Than T-Tube Drainage after Conventional CBD Exploration for Choledocholithiasis

Objective

We are trying to investigate the possibility, safety, and benefits of replacing the role of T-tube by another more safe and effective procedure for biliary decompression in the case of common bile duct (CBD) exploration.

Methods

Our present study includes fifty consecutive patients who underwent a traditional CBD exploration due to choledocholithiasis. Patients were divided into 2 equal groups. In the 1^st group, a spontaneously expelled Nelaton tube is placed in the CBD to aid in bile drainage to the duodenum, while in the 2^nd group, a conventional T-tube is placed to decompress the CBD in the early postoperative (PO) days to a drainage bag. Operative and PO data as well as PO hospital stay time were recorded. All data were collected and statistically analyzed.

Results

The mean operative time and PO hospital stay days were significantly low (p value < 0.05) in the Nelaton tube drainage group compared with the T-tube drainage group. On the other hand, the mean time needed for the abdominal drain removal was significantly higher in the T-tube drainage group (p value < 0.05).

Conclusion

Nelaton tube with internal biliary drainage is effective and safer than T-tube drainage and it helps in reduction of the PO hospital stay time. In addition, it avoids all short-term complications of T-tube.

Selective Antegrade Biliary Stenting Aids Emergency Laparoscopic Cholecystectomy

Background: Symptomatic gall stone disease requires early emergency treatment to prevent complications. This early treatment is often delayed due to difficulty in the diagnosis and management of concomitant choledocholithiasis. Intervention with preoperative endoscopic retrograde cholangiopancreatography (ERCP) is associated with complications and known to be unnecessary in most cases. We follow a strategy of providing early cholecystectomy with selective utility of antegrade stent in cases of choledocholithiasis. Our main aim is to present our technique and results. Method: We conducted a 3-year (January 2014 to January 2017) review of a prospectively maintained database of our practice of performing routine intraoperative cholangiogram (IOC) during laparoscopic cholecystectomy (LC) and when choledocholithiasis is encountered on IOC; a transcystic antegrade biliary stent is inserted to decompress the common bile ducts (CBD) and facilitate postoperative ERCP at later date. Results: Of the 411 cholecystectomies performed, 77.3% were females with mean age of 48 years. Seventy-four patients were found to have CBD stones (CBDS) on IOC. Antegrade stents were successfully deployed in 69 cases. Even though Antegrade stents were done more frequently in emergency admissions (P = .001); this did not increase the length of hospital stay (LOHS) (P = .752) or the rate of complications (P = .171). However, doing a preoperative ERCP significantly increased LOHS (P = .001), and 67% of these needed two or more ERCP for complete clearance of CBD and had more complications. Nine (15.2%) out of 59 patients with pancreatitis had CBDS on IOC and were successfully managed with antegrade stent. Conclusion: This strategy can be followed by general surgeons, enabling them to perform LC in the presence of choledocholithiasis during acute admissions including pancreatitis. It does not require any specialist skills in CBD exploration and also eliminates unnecessary preoperative ERCP and avoids its potential complications.

Spontaneously removed biliary stent drainage versus T-tube drainage after laparoscopic common bile duct exploration

Several studies have shown the safety and feasibility of laparoscopic common bile duct exploration (LCBDE) as a minimally invasive treatment options for choledocholithiasis. Use of T-tube or biliary stent drainage tube placement after laparoscopic choledochotomy for common bile duct (CBD) stones is still under debate. This study tried to confirm the safety of spontaneously removable biliary stent in the distal CBD after LCBDE to allow choledochus primary closure. A total of 47 patients with choledocholithiasis underwent LCBDE with primary closure and internal drainage using a spontaneously removable biliary stent drainage tube (stent group, N = 22) or T-tube (T-tube group, N = 25). Operative parameters and outcomes are compared. Surgical time, intraoperative blood loss, length of hospital stay, drainage tube removal time, postoperative intestinal function recovery, and cost of treatment were all significantly lower in the stent group as compared to that in the T-tube group (P < 0.05 for all). Otherwise, Bile leakage between the two groups had no significant difference (P > 0.05). The biliary stent drainage tube was excreted spontaneously 4 to 14 days after surgery with the exception of one case, where endoscopic removal of biliary tube was required due to failure of its spontaneous discharge. LCBDE with primary closure and use of spontaneously removable biliary stent drainage showed advantage over the use of traditional T-tube drainage in patients with choledocholithiasis.

Clinical effects of laparoscopic common bile duct exploration and T-tube drainage in elderly patients with a history of upper abdominal operation

AIM: To assess the feasibility, effectiveness, and safety of laparoscopic common bile duct exploration and T-tube drainage (LCBDE-TD) in elderly patients with a history of upper abdominal operation, and summarize the surgical methods and skills.

METHODS: The clinical data for 28 elderly patients (>60 years) with a history of upper abdominal operation from January 2012 to December 2013 were retrospectively analyzed. Of these patients, 15 underwent LCBDE-TD and 13 underwent open common bile duct exploration and T-tube drainage (OCBDE-TD). The average time of operation, intro-operative blood loss, time to recovery of gastrointestinal function and postoperative hospitalization time were compared between the two groups.

RESULTS: All the patients were operated successfully. The operative time for the laparoscopy group and open group was, respectively, 120.4 min ± 40.6 min and 164.4 min ± 47.9 min (P = 0.014 < 0.05). The intro-operative blood loss was 62.0 mL ± 33.4 mL and 110.8 mL ± 52.8 mL, respectively (P = 0.006 < 0.05). The time to postoperative recovery of gastrointestinal function was 3.9 d ± 1.0 d and 4.9 d ± 1.1 d, respectively (P = 0.022 < 0.05). The postoperative hospitalization time was 8.5 d ± 2.2 d and 13.4 d ± 5.0 d, respectively (P = 0.002 < 0.05).

CONCLUSION: LCBDE-TD for elderly patients with a history of upper abdominal operation has the advantages of shorter operative time, less intra-operative blood loss, faster recovery of gastrointestinal function, and shorter hospitalization than open surgery.

Clinical effects of laparoscopic common bile duct exploration vs laparoscopic common bile duct exploration plus T-tube drainage in treatment of secondary extrahepatic bile duct stones

AIM: To compare the clinical effects of laparo-scopic transcyctic common bile duct exploration (LTCBDE) and laparoscopic common bile duct exploration (LCBDE) plus T-tube drainage in the treatment of extrahepatic bile duct stones.

METHODS: Ninety patients with secondary extrahepatic bile duct stones treated from January 2012 to June 2014 at our hospital were divided into either an observation group or a control group, with 45 cases in each group. The observation group received LTCBDE, and the control group received LCBDE plus T-tube drainage. Operative time, intraoperative blood loss, hospitalization expenses, and postoperative complications were compared between the two groups.

RESULTS: The operative time was significantly longer in the observation group than in the control group, but intraoperative blood loss, postoperative hospital stay, postoperative rehydration, postoperative hospitalization expenses, and time to tube removal were significantly lower in the observation group than in the control group. The incidence rates of early and late complications were significantly lower in the observation group than in the control group (2.22% vs 13.33%, 0 vs 11.11%, χ² = 7.349 and 5.281, respectively, P < 0.05).

CONCLUSION: As long as the surgical indications are properly selected, LTCBDE is minimally invasive and associated with less complications and faster postoperative recovery than LCBDE plus T-tube drainage in the treatment of secondary extrahepatic bile duct stones.

Use of biliary stent in laparoscopic common bile duct exploration

INTRODUCTION

It is well supported in the literature that laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis has equal efficacy when compared to ERCP followed by laparoscopic cholecystectomy. Decompression after supra-duodenal choledochotomy is common practice as it reduced the risk of bile leaks. We conducted a prospective non-randomized study to compare outcomes and length of stay in patients undergoing biliary stent insertion versus T-tube drainage following LCBDE via choledochotomy.

METHODS AND PROCEDURES

The study involved 116 patients with choledocholithiasis who underwent LCBDE and decompression of the biliary system by either ante-grade biliary stent or T-tube insertion. A 7 French straight/duodenal curve biliary Diagmed™ stent (9-11 cm) was placed in 82 patients (Biliary Stent Group). T-tube insertion was used for 34 patients (T-tube group). The length of hospital stay and complications for the selected patients were recorded. All trans-cystic common bile duct explorations were excluded from the study.

RESULTS

The mean hospital stay for patients who underwent ante-grade biliary stent or T-tube insertion after LBCDE were 1 and 3.4 days, respectively. This is a statistically significant result with a p value of less than 0.001. Of the T-tube group, two patients required laparoscopic washout due to bile leaks, one had ongoing biliary stasis and one reported ongoing pain whilst the T-tube was in situ. A complication rate of 11.2%, this was a significant finding. There were no complications or concerns reported for the Biliary Stent Group.

CONCLUSION

Our results show that there is a significant reduction in length of hospital stay and morbidity for patients that have ante-grade biliary stent decompression of the CBD post laparoscopic choledochotomy when compared T-tube drainage. This implies that ante-grade biliary stent insertion is likely to reduce costs and increase overall patient satisfaction. We support the use of ante-grade biliary stent insertion during LCBDE when primary closure is not preferred.