Laparoscopic bile duct exploration via choledochotomy followed by primary duct closure is feasible and safe for the treatment of choledocholithiasis

Outcomes of laparoscopic choledochotomy using cholangioscopy via percutaneous-choledochal tube for the treatment of hepatolithiasis and choledocholithiasis: A preliminary Vietnamese study

Backgrounds/Aims

Hepatolithiasis and choledocholithiasis are frequent pathologies and unfortunately, with the current treatment strategies, the recurrence incidence is still high. This study aimed to assess the outcomes of laparoscopic choledochotomy using cholangioscopy via the percutaneous-choledochal tube for the treatment of hepatolithiasis and choledocholithiasis in Vietnamese patients.

Methods

A cross-sectional study of patients with hepatolithiasis and/or choledocholithiasis who underwent laparoscopic choledochotomy using intraoperative cholangioscopy via percutaneous-choledochal tube at the Department of Hepatopancreatobiliary Surgery, 108 Military Central Hospital, from June 2017 to March 2020.

Results

A total of 84 patients were analyzed. Most patients were females (56.0%) with a median age of 55.56 years. Among them, 41.8% of patients had previous abdominal operations, with 33.4% having choledochotomy. All patients underwent successful laparoscopic common bile duct exploration followed by T-tube drainage without needing to convert to open surgery. Most patients (64.3%) had both intrahepatic and extrahepatic stones. The rate of stones ≥ 10 mm in diameter was 64.3%. Biliary strictures were observed in 19.1% of patients during cholangioscopy. Complete removal of stones was achieved in 54.8% of patients. Intraoperative complications were encountered in two patients, but there was no need to change the strategy. The mean operating time was 121.85 ± 30.47 minutes. The early postoperative complication rate was 9.6%, and all patients were managed conservatively. The residual stones were removed through the T-tube tract by subsequent choledochoscopy in 34/38 patients, so the total success rate was 95.2%.

Conclusions

Laparoscopic choledochotomy combined with cholangioscopy through the percutaneous-choledochal tube is a safe and effective strategy for hepatolithiasis and/or choledocholithiasis, even in patients with a previous choledochotomy.

Evaluation of the ACS NSQIP surgical risk calculator in patients undergoing common bile duct exploration

PURPOSE

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical risk calculator is a risk stratification tool to help predict risks of postoperative complications, which is important for informed decision-making. The purpose of this study was to evaluate the accuracy of the calculator in predicting postoperative complications in patients undergoing common bile duct (CBD) exploration.

METHODS

A retrospective chart review was completed for 305 patients that underwent open and laparoscopic CBD exploration at a single institution from 2010 to 2018. Patient demographics and preoperative risk factors were entered into the calculator, and the predicted complication risks were compared with observed complication rates. Brier score, C-statistic, and Hosmer-Lemeshow regression analysis were used to assess discrimination and calibration.

RESULTS

The observed rate exceeded the predicted rate for any complication (35.1% vs. 21%), return to operating room (5.9% vs. 3.6%), death (3.3% vs. 1%), and sepsis (3% vs. 2.4%). The model performed best in predicting serious complication (Brier 0.087, C-statistic 0.818, Hosmer-Lemeshow 0.695), surgical site infection (Brier 0.068, C-statistic 0.670, Hosmer-Lemeshow 0.292), discharge to rehabilitation facility (Brier 0.041, C-statistic 0.907, Hosmer-Lemeshow 0.638), and death (Brier 0.028, C-statistic 0.898, Hosmer-Lemeshow 0.004). In multivariable analysis, there was no statistically significant predicted complication type that affected the type of surgery.

CONCLUSION

The calculator was accurate in predicting serious complication, surgical site infection, discharge to rehabilitation facility, and death. However, the model displayed poor predictive ability in all other complications that were analyzed.

Primary Closure vs T-Tube Drainage Following Open Choledochotomy for CBD (Common Bile Duct) Stones

BACKGROUND

Choledocholithiasis affects 10%-15% of individuals with gallbladder stones. Approximately 7%-15% of cholecystectomy patients develop common bile duct (CBD) stones. It occurs more frequently in older age groups. It may result in a complete or partial blockage of the bile duct and present as pancreatitis or cholangitis due to gallstones.

OBJECTIVE

The aim of this study was to compare the outcomes of primary closure of duct and T-tube drainage after open choledochotomy and to evaluate the effectiveness and safety of primary closure.

MATERIAL AND METHODS

From January 2018 to December 2021, this descriptive study was carried out in the surgical department of the Hayatabad Medical Complex in Peshawar. In total, 60 patients who had open choledocholithotomy after a failed endoscopic extraction were included in this study. Of these, 30 (50%) patients got primary duct closure after choledochotomy, while 30 (50%) patients had T-tube insertion.

RESULTS

 Among the total of 60 patients (primary closure: 30 and T-tube drainage: 30 patients), 10 (16%) were males, while 50 (84%) were female patients. The mean age was recorded as 45.9±13.9, and the mean hospital stay in days in both groups was 4.87±1.4 (T-tube: 5.24±1.50 and primary closure: 4.50±1.3). Complications developed in group A were a biliary leak in three (10%) patients, postoperative jaundice in two (6.5%) patients, wound infection in three (10%), intra-abdominal collection in three (10%) patients, and dislodgement of a tube in two (6.5%), while 17 (57%) patients had no complications developed.

CONCLUSION

 If the duct is free of stones, as determined by preoperative choledochoscopy, primary closure of the common bile duct (CBD) is a safe, cost-effective procedure with less morbidity than regular T-tube drainage after open choledochotomy.

Laparoscopic Transcystic Common Bile Duct Exploration: 8-Year Experience at a Single Institution

BACKGROUND

Laparoscopic transcystic common bile duct exploration (LTCBDE) is used to treat cholecystolithiasis and choledocholithiasis. This study aimed to investigate the safety, effectiveness and generalisability of LTCBDE in patients with cholecystolithiasis and choledocholithiasis based on our LTCBDE experience within 8 years.

METHODS

Four hundred patients with cholecystolithiasis and choledocholithiasis (including 62 of cholecystolithiasis and choledocholithiasis with common bile duct no-dilatation) treated with LTCBDE at a single centre from January 2014 to February 2022 were retrospectively evaluated. They were divided into the first 200 and last 200 LTCBDE cases. The disease characteristics, cystic duct incision methods, surgical outcomes and follow-up data were analysed retrospectively. Each patient was followed up for > 3 months.

RESULTS

Four hundred patients underwent LTCBDE, including 188 males and 212 females aged from 15 to 91 years (average age: 56 years). LTCBDE was successful in 377 (94.3%) patients, while treatment was converted to laparoscopic choledocholithotomy with T-tube drainage in 23 (5.8%), owing to intraoperative choledochoscope insertion failure. The CBD diameter (10.89 ± 1.76 vs 9.97 ± 2.39, P < 0.05), cystic duct diameter (4.62 ± 1.03 vs 5.03 ± 1.29, P < 0.05), and operation time (164.60 ± 24.30 vs 135.34 ± 30.00, P < 0.05). Residual stones were found in six (1.5%) patients and removed during the second operation; post-operative bile leakage was found in one (0.3%) patient, who was discharged safely after the second operation.

CONCLUSIONS

Phase I LTCBDE is safe and effective in treating cholecystolithiasis and choledocholithiasis. With continuous technological advances, LTCBDE has been effectively promoted and applied.

Safety and Feasibility of Primary Closure Following Laparoscopic Common Bile Duct Exploration for Treatment of Choledocholithiasis

BACKGROUND

T-tube drainage following laparoscopic common bile duct (CBD) exploration may lead to T-tube displacement and water-electrolyte disorders, affecting patients' quality of life. In particular, biliary peritonitis may develop in a small number of patients after T-tube removal, requiring reoperation. This prospective cohort study was performed to investigate the safety and feasibility of primary closure following laparoscopic CBD exploration for the treatment of choledocholithiasis.

METHODS

Patients who were treated for choledocholithiasis by laparoscopic CBD exploration with primary closure from January 2019 to March 2022 comprised the PC group (n = 145). Patients who were treated for choledocholithiasis by laparoscopic CBD exploration with T-tube drainage during this period comprised the TD group (n = 153). Perioperative and follow-up outcomes were collected and statistically analyzed.

RESULTS

The TD and PC groups showed significant differences in the operation time (124.6 ± 40.8 vs. 106 ± 36.4 min, P = 0.000) and postoperative hospital stay (7.1 ± 2.6 vs. 5.9 ± 2.0 days, P = 0.000). No significant difference was observed in terms of blood loss, the ratio of conversion to laparotomy, and postoperative parameters. Preoperative albumin and total bilirubin levels were the risk factors of bile leakage after surgery. No patients developed CBD stricture or carcinogenesis, The rates of residual and recurrent stones in the TD and PC groups were 1.97% vs. 1.40% and 1.31% vs. 1.40%, respectively, with no significant difference (P = 1.000 for both).

CONCLUSIONS

Primary closure following laparoscopic CBD exploration is safe and feasible for selected patients with choledocholithiasis.

Intraoperative ultrasound-guided percutaneous hepatocholangiostomy applied in the cholangioscopic lithotripsy for hepatolithiasis and choledocholithiasis

BACKGROUND

Percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) is a minimally invasive treatment for hepatolithiasis. But it may make a long cycle of treatment so that it was further improved to complete the percutaneous hepatic choledochotomy and choledochoscopic lithotripsy in phase I surgery. The aim of this study was to evaluate the efficacy of the modified technique comparing with laparoscopic choledochotomy.

METHODS

Retrospective analysis of the clinical data of patients with hepatolithiasis or choledocholithiasis consulted at our hospital from February 2018 to December 2021. The cases were divided into two groups according to surgical modality, intraoperative ultrasound-guided percutaneous transhepatic cholangioscopic lithotripsy (IUG-PTCSL) and laparoscopic choledochotomy lithotripsy (LC-L). Contrast analysis determined the advantages of the two approaches.

RESULTS

IUG-PTCSL was performed in 44 patients, aged 58.14 ± 14.01 years, including 9 male and 35 female. There were 15 patients underwent LC-L, aged 62.13 ± 15.03 years, including 1 male and 14 female. There was not statistically significant difference in the composition of patients' age and sex between the two groups (p = 0.356, 0.219). The success rate of intraoperative ultrasound-guided percutaneous hepatic bile duct puncture was 100% followed with the success rate of hepatocholangiostomy was 100%. Although 1 (1/44) patient showed significant bleeding during choledochoscopic lithotripsy and was converted to open choledochotomy for stone extraction, 43 patients completed IUG-PTCSL with the rate of phase I surgical stones removal was 81.40% (35/43), whereas the stones removal rate of LC-L was 66.67% (10/15). There was not statistically significant difference between them (p = 0.067). Both the groups showed no significant complications with the postoperative hospital stay of 8 (6, 10) days and 10 (8, 11) days, respectively, and the difference was statistically significant (p = 0.028).

CONCLUSION

Intraoperative ultrasound-guided percutaneous transhepatic cholangioscopy might be a safe and reliable ideal method for bile duct stones with the advantages of rapid recovery for patients. Intraoperative ultrasound-guided percutaneous hepatocholangiostomy may be the key technique for the successful completion of the surgery.

The clinical effect of primary duct closure and T-tube drainage: A propensity score matched study

BACKGROUND

Although laparoscopic common bile duct exploration (LCBDE) is considered a safe and effective method for the removal of bile duct stones, selecting primary duct closure (PDC) or T-tube drainage (TTD) following choledochotomy remains controversial. This study aims to explore the clinical effects of PDC and TTD after LCBDE.

METHODS

We retrospectively analyzed clinical data of 348 patients with choledocholithiasis treated with LCBDE from January 2016 to October 2020. All patients were divided into PDC (225 cases) and TTD (123 cases) groups. Propensity score matching (PSM) was performed. We compared operative parameters and outcomes.

RESULTS

After matching (n = 116/group), no significant difference was observed between the two groups (P > 0.05) regarding intra-abdominal infection, incision infection, bile leakage, and retained stones. In terms of operation time, intraoperative blood loss, postoperative hospital stay, postoperative exhaust time, postoperative antibiotic use time, and postoperative abdominal drainage time, PDC group was obviously superior to TTD group (P < 0.05).

CONCLUSION

Primary closure following LCBDE is considered a safe and effective alternative to T-tube drainage.

Comparative study of three common bile duct closure techniques after choledocholithotomy: safety and efficacy

PURPOSE

T-tube drainage, primary closure, and biliary stenting are the common bile duct closure methods. There is great debate on the optimal duct closure technique after common bile duct exploration. This study aimed to assess the safety and efficacy of the three commonest common bile duct closure methods after common bile duct exploration for common bile duct stone for future generalization.

METHODS

In this analysis, 211 patients with common bile duct stone underwent common bile duct exploration from January 2016 to December 2020. The patients were divided according to common bile duct closure techniques into three groups, including the T-tube drainage group (63 patients), primary duct closure group (61 patients), and antegrade biliary stenting group (87 patients).

RESULTS

The incidence of overall biliary complications and bile leak were statistically significantly lower in the biliary stenting group than in the other two groups. Also, hospital stays, drain carried time, return to normal activity, re-intervention, and re-admission rates were statistically significantly lower in the biliary stenting group than in the other two groups. There were no statistically significant differences regarding operative and choledochotomy time, retained and recurrent stone, stricture, biliary peritonitis, cholangitis, and the cost among the three groups.

CONCLUSIONS

We state that the biliary stenting procedure should be the preferred first option for common bile duct closure after common bile duct exploration when compared with T-tube drainage and primary duct closure.

TRIAL REGISTRATION

ClinicalTrials.gov PRS (Approval No. NCT04264299).

Primary closure after laparoscopic common bile duct exploration is safe and feasible for patients with non-severe acute cholangitis

BACKGROUND

The safety and feasibility of primary closure after laparoscopic common bile duct exploration (LCBDE) have been confirmed in elective settings. However, the suitability of primary closure after LCBDE in the treatment of patients with non-severe acute cholangitis in emergency settings remains unclear. The aim of the present study was to explore the safety and feasibility of LCBDE with primary closure in patients with non-severe acute cholangitis.

METHODS

Consecutive patients with choledocholithiasis combined with gallbladder stones treated by LCBDE with primary closure at our institution from January 2015 to April 2021 were retrospectively reviewed. These patients were divided into two groups: emergency group (patients with non-severe acute cholangitis) and elective group (patients without acute cholangitis). The demographic and perioperative data of the two groups were compared.

RESULTS

One hundred twenty-two patients received LCBDE combined with primary closure during this period, including 70 in the emergency group and 52 in the elective group. Baseline characteristics were balanced in both groups, except for higher levels of white blood cells (WBC), C-reactive protein (CRP), total bilirubin, alkaline phosphatase (ALP), and albumin in the emergency group. No postoperative mortality occurred in either group. Compared to the elective group, the emergency group had a longer operation time (P = 0.011), and more estimated blood loss (P < 0.001). No significant differences were found between the two groups in terms of conversion (2.9% vs. 0.0%, P = 0.507), use of baskets (84.2% vs. 78.8%, P = 0.481), use of electrohydraulic lithotripsy (EHL) (2.9% vs. 1.9%, P = 1.000), or postoperative hospital stay (P = 0.214). The incidence of postoperative complications was comparable between the two groups. During the follow-up period, none of the patients experienced biliary stricture, and 1 case of stone recurrence occurred in the elective group.

CONCLUSIONS

LCBDE with primary closure for choledocholithiasis patients with non-severe acute cholangitis has the equivalent efficacy and morbidity to elective surgery. Primary closure after LCBDE is a safe and feasible option for choledocholithiasis patients with non-severe acute cholangitis.

Primary closure versus T-tube drainage after laparoscopic common bile duct exploration in patients with non-severe acute cholangitis

Although the feasibility of T-tube drainage after emergency laparoscopic common bile duct exploration (LCBDE) has been reported, the safety and effectiveness of primary closure (PC) after LCBDE in patients with non-severe acute cholangitis (AC) remain uncertain. This study aimed to investigate the safety and feasibility of PC after LCBDE in patients with non-severe AC. Consecutive choledocholithiasis patients with non-severe AC who were treated with a laparoscopic approach at our institution between January 2014 and March 2021 were enrolled. These patients were divided into two groups (PC group and T-tube group) based on the way of closure of the common bile duct. The baseline characteristics and perioperative data between the two groups were compared. A total of 230 patients who underwent LCBDE met the inclusion criteria, and there were 94 patients in the PC group and 126 patients in the T-tube group. Baseline data were balanced between the two groups, except that there was less acute cholecystitis in the PC group than in the T-tube group (P = 0.027). Compared to the T-tube group, the PC group had a shorter operation time (P < 0.001), less estimated blood loss (P < 0.001), less use of electrohydraulic lithotripsy (EHL) (P = 0.001), shorter time of drainage removal (P < 0.001) and postoperative hospital stay (P < 0.001) and residual stones (P = 0.029). There was no significant difference between the two groups in terms of conversion (4.3 vs. 4.4%, P = 1.000), intraoperative transfusion (0.0 vs. 0.7%, P = 1.000), use of basket (71.2 vs. 69.9%, P = 0.816), postoperative bleeding (1.1 vs. 0.7%, P = 1.000), biliary leakage (4.3 vs. 3.7%, P = 1.000), incision infection (1.1 vs. 2.2%, P = 0.649), pneumonia (2.1 vs. 1.4%, P = 1.000), or cholangitis (1.1 vs. 2.9%, P = 0.651). No postoperative mortality occurred in either group. During the follow-up period, no biliary stricture occurred in the two groups, and two patients in the T-tube group were found to have stone recurrence. PC after LCBDE in choledocholithiasis patients with non-severe AC shows superior clinical outcomes to T-tube drainage in terms of the operation time, estimated blood loss, time of drainage removal, postoperative hospital stay, and residual stones. PC is a safe and feasible treatment for choledocholithiasis patients with non-severe AC after LCBDE.

Laparoscopic common bile duct exploration after failed endoscopic retrograde cholangio-pancreatography: Our patient series over a period of 10 years

Aim:

Laparoscopic CBD exploration (LCBDE) for Common bile duct (CBD) stones with laparoscopic cholecystectomy (LC) is an alternative to open CBD exploration, in patients with failed endoscopic retrograde cholangio-pancreatography (ERCP). It is being performed at few centres with adequate surgical expertise. Herein, we present our experience of LCBDE with LC over a period of 10 years.

Patients and Methods:

A retrospective analysis of prospectively recorded data of 121 consecutive patients was performed from February 2010 to November 2019, who underwent LC and LCBDE by choledochotomy in a single surgical unit. These included all patients with failed pre-operative ERCP.

Results:

Out of 121 patients, LCBDE successfully cleared the CBD in 118, and three patients were converted to open surgery. All these patients underwent choledochotomy for adequate exploration of CBD. T-tube closure of CBD was performed in 103 patients and removed after a mean of 14.6 ± 2.4 days. Primary closure was performed in 15 patients. The mean hospital stay post-procedure was 3.4 ± 0.7 days. Complete ductal clearance was achieved in 115 patients, and residual stone fragments reported in three patients were removed by ERCP. None of the patients experienced biliary peritonitis, biliary fistula, pancreatitis or cholangitis. There was no 30-day mortality and no recurrent stones reported with a mean follow-up of 12.4 ± 3.9 months.

Conclusion:

With adequate surgical expertise, LCBDE is a feasible alternative to open surgery for CBD stones after failed ERCP with early recovery and low morbidity.

Efficacy and safety of laparoscopic common bile duct exploration via choledochotomy with primary closure for the management of acute cholangitis caused by common bile duct stones

Background

T-tube drainage after laparoscopic common bile duct exploration (LCBDE) has been demonstrated to be safe and effective for patients with acute cholangitis caused by common bile duct stones (CBDSs). The outcomes after LCBDE with primary closure in patients with CBDS-related acute cholangitis are unknown. The present study aimed to evaluate the efficacy and safety of LCBDE with primary closure for the management of acute cholangitis caused by CBDSs.

Methods

Between June 2015 and June 2020, 368 consecutive patients with choledocholithiasis combined with cholecystolithiasis, who underwent laparoscopic cholecystectomy (LC) + LCBDE in our department, were retrospectively reviewed. A total of 193 patients with CBDS-related acute cholangitis underwent LC + LCBDE with primary closure of the CBD (PC group) and 62 patients underwent LC + LCBDE followed by T-tube placement (T-tube group). A total of 113 patients who did not have cholangitis were excluded. The clinical data were compared and analyzed.

Results

There was no mortality in either group. No significant differences were noted in morbidity, bile leakage rate, retained CBD stones, or readmission rate within 30 days between the two groups. Compared with the T-tube group, the PC group avoided T-tube-related complications and had a shorter operative time (121.12 min vs. 143.37 min) and length of postoperative hospital stay (6.59 days vs. 8.81 days). Moreover, the hospital expenses in the PC group were significantly lower than those in the T-tube group ($4844.47 vs. $5717.22). No biliary stricture occurred during a median follow-up of 18 months in any patient. No significant difference between the two groups was observed in the rate of stone recurrence.

Conclusions

LCBDE with primary closure is a safe and effective treatment for cholangitis caused by CBDSs. LCBDE with primary closure is not inferior to T-tube drainage for the management of CBDS-related acute cholangitis in suitable patients.

Comparison of Primary Suture and T-Tube Drainage After Laparoscopic Common Bile Duct Exploration Combined with Intraoperative Choledochoscopy in the Treatment of Secondary Common Bile Duct Stones: A Single-Center Retrospective Analysis

Objective: To compare the safety and feasibility of T-tube drainage and primary suture after laparoscopy combined with choledochoscopy in the treatment of secondary choledocholithiasis. Methods: The clinical data of patients who underwent laparoscopic choledochoscopy combined with choledochoscopic common bile duct exploration (LCBDE) for secondary choledocholithiasis from June 2015 to June 2020 were analyzed retrospectively. According to the different treatment method of common bile duct (CBD) incision, the patients were divided into a T-tube drainage group and a primary suture group. The preoperative clinical characteristics, results of preoperative liver function tests (LFTs), LFTs on the first day after the operation and the fourth day after the operation, operation time, intraoperative bleeding, postoperative complications, and times of postoperative hospital stay were compared between the two groups. Results: There was no significant difference in preoperative clinical data, preoperative LFTs, and postoperative complications between the two groups (P > .05). However, primary suture demonstrated significant advantages (P < .05) in terms of the operation time, intraoperative blood loss, postoperative hospital stay, and other related factors. Bilirubin levels on the first day after the operation and the fourth day after the operation between the two groups suggested that T-tube drainage reduces bilirubin in the short term, but that long-term bilirubin draining is similar between the two strategies. Univariate and multivariate analyses showed that choledochal diameter less than 8 mm was an independent risk factor for bile leakage. Conclusions: Laparoscopy combined with intraoperative choledochoscopic CBD exploration is superior to T-tube drainage in terms of the operation time, intraoperative blood loss, and postoperative hospital stay. The ability of reducing bilirubin by traditional T-tube drainage is indeed better than that of primary suture in the early stage after operation, but there is no difference in long-term outcome between the two groups. Choledochal diameter ≤8 mm was an independent risk factor for bile leakage. To summarize, LCBDEs primary suture for secondary choledocholithiasis is safe and feasible.

Application of an internal drainage tube in laparoscopic common bile duct exploration

Choledocholithiasis is a common disease of the biliary system. The traditional surgical method for this is to remove the gallbladder, open the common bile duct, remove the stones and place a T-tube in the common bile duct for drainage. Common bile duct exploration usually requires a T-tube. Without a T-tube, there is a risk of bile leakage due to pressure in the bile duct. After the T-tube is placed, patients experience some form of discomfort and inconveniences with daily life, and there is also a risk of accidental detachment, as well as a risk of bile leakage when the T-tube is removed. In severe cases, patients may need to be hospitalized again. With advancements being made in surgical instruments and technology, laparoscopic common bile duct exploration has been widely used. Due to the carbon dioxide pneumoperitoneum, laparoscopic common bile duct exploration requires a long period of time for T-tube sinus formation compared with open surgery. Therefore, the extubation time needs to be prolonged in laparoscopic common bile duct exploration. The use of an internal drainage tube may be used in order to avoid the aforementioned disadvantages. Since 2012, the authors have performed laparoscopic common bile duct exploration with the placement of an internal drainage tube for the treatment of common bile duct stones, and have completed >160 surgeries. The present study provides a summary of the data of these 160 cases. The 160 patients underwent laparoscopic cholecystectomy. Following the removal of the stones, an internal drainage tube was placed, and the common bile duct incision was primary sutured. All patients were discharged, and there were no complications, such as biliary leakage, biliary bleeding and biliary stricture. On the whole, the present study demonstrates that where possible, the placement of an internal drainage tube in laparoscopic common bile duct exploration is safe and reliable, and may be used to avoid the risk of bile leakage without a T-tube, any inconveniences for patients, and the risk of bile leakage following the removal of the T-tube.

Outcomes of laparoscopic bile duct exploration for choledocholithiasis with small common bile duct

BACKGROUND

Laparoscopic cholecystectomy (LC) combined with laparoscopic common bile duct (CBD) exploration (LCBDE) is one of the main treatments for choledocholithiasis with CBD diameter of larger than 10 mm. However, for patients with small CBD (CBD diameter ≤ 8 mm), endoscopic sphincterotomy remains the preferred treatment at present, but it also has some drawbacks associated with a series of complications, such as pancreatitis, hemorrhage, cholangitis, and duodenal perforation. To date, few studies have been reported that support the feasibility and safety of LCBDE for choledocholithiasis with small CBD.

AIM

To investigate the feasibility and safety of LCBDE for choledocholithiasis with small CBD.

METHODS

A total of 257 patients without acute cholangitis who underwent LC + LCBDE for cholecystolithiasis from January 2013 to December 2018 in one institution were reviewed. The clinical data were retrospectively collected and analyzed. According to whether the diameter of CBD was larger than 8 mm, 257 patients were divided into large CBD group (n = 146) and small CBD group (n = 111). Propensity score matching (1:1) was performed to adjust for clinical differences. The demographics, intraoperative data, short-term outcomes, and long-term follow-up outcomes for the patients were recorded and compared.

RESULTS

In total, 257 patients who underwent successful LC + LCBDE were enrolled in the study, 146 had large CBD and 111 had small CBD. The median follow-up period was 39 (14-86) mo. For small CBD patients, the median CBD diameter was 0.6 cm (0.2-2.0 cm), the mean operating time was 107.2 ± 28.3 min, and the postoperative bile leak rate, rate of residual CBD stones (CBDS), CBDS recurrence rate, and CBD stenosis rate were 5.41% (6/111), 3.60% (4/111), 1.80% (2/111), and 0% (0/111), respectively; the mean postoperative hospital stay was 7.4 ± 3.6 d. For large CBD patients, the median common bile duct diameter was 1.0 cm (0.3-3.0 cm), the mean operating time was 115.7 ± 32.0 min, and the postoperative bile leak rate, rate of residual CBDS, CBDS recurrence rate, and CBD stenosis rate were 5.41% (9/146), 1.37% (2/146), 6.85% (10/146), and 0% (0/146), respectively; the mean postoperative hospital stay was 7.7 ± 2.7 d. After propensity score matching, 184 patients remained, and all preoperative covariates except diameter of CBD stones were balanced. Postoperative bile leak occurred in 11 patients overall (5.98%), and no difference was found between the small CBD group (4.35%, 4/92) and the large CBD group (7.61%, 7/92). The incidence of CBDS recurrence did not differ significantly between the small CBD group (2.17%, 2/92) and the large CBD group (6.52%, 6/92).

CONCLUSION

LC + LCBDE is safe and feasible for choledocholithiasis patients with small CBD and did not increase the postoperative bile leak rate compared with chole-docholithiasis patients with large CBD.

One-step percutaneous transhepatic cholangioscopic lithotripsy in patients with choledocholithiasis

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) may be inappropriate for most patients with choledocholithiasis. This study aimed to evaluate one-step percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) in the treatment of patients with choledocholithiasis who could not undergo ERCP (e.g., failed ERCP, altered anatomy, and/or contra-indications).

METHOD

This was a retrospective single-centre series of 67 patients who underwent choledocholithiasis between November 2015 and March 2018: 35 with one-step PTCSL (Group A) and 32 with laparoscopic common bile duct (CBD) exploration (Group B).

RESULTS

Compared with Group B, Group A showed shorter duration of operation, length of stay in the hospital, postoperative hospital stay, postoperative drainage time, and time to oral intake (all P<0.05). Intraoperative blood loss, costs, conversion to open surgery (one in group A vs. seven in group B; P=0.023), and bile leakage (none in group A vs. four in group B; P=0.047) were lower in Group A than in Group B. There were no significant differences between the two groups regarding the intraoperative clearance rate, ultimate clearance rate, and several postoperative complications.

CONCLUSION

One-step PTCSL could be an alternative for patients with choledocholithiasis, especially when ERCP is not feasible.

Primary Two-Layered Closure of the Common Bile Duct Reduces Postoperative Bile Leakage After Laparoscopic Common Bile Duct Exploration

Objective: The effectiveness and feasibility of the primary closure after laparoscopic common bile duct exploration (LCBDE) have been well demonstrated, however, the incidence of postoperative bile leakage after LCBDE remains high. The current study aimed at investigating whether our new suturing method could reduce the risk of bile leakage after LCBDE. Materials and Methods: This retrospective study included 81 patients who underwent primary two-layered closure or traditional primary closure of the common bile duct (CBD) after LCBDE, and the related clinical data were compared and analyzed. Results: The primary two-layered closure group had a lower rate of bile leakage compared with the traditional primary closure group (P < .05). There were no significant differences in additional parameters, such as operative time, estimated blood loss, postoperative stay duration, time to drain removal, postoperative pancreatitis, stone recurrence, and overall morbidity. No patients developed bile duct stenosis during the follow-up period. Conclusions: Primary two-layered closure of CBD can reduce the postoperative bile leakage after LCBDE. Moreover, it is a safe and effective therapeutic option for patients with choledocholithiasis.

The Safety and Efficacy of Primary Duct Closure without Endoscopic Nasobiliary Drainage after Laparoscopic Common Bile Duct Exploration

Background

Primary duct closure (PDC) after laparoscopic common bile duct exploration (LCBDE) has been widely applied for choledocholithiasis. However, there has been controversy over the placement of endoscopic nasobiliary drainage (ENBD) during operation. To date, few studies compare the clinical effect of PDC without and with ENBD. The aim of this study was to assess the safety and efficacy of PDC without ENBD for choledocholithiasis.

Methods

From January 2016 to December 2018, a total of 164 patients meeting the inclusion criteria were enrolled and divided into group A (undergone LCBDE + PDC without ENBD, 81 cases) and group B (undergone LCBDE + PDC with ENBD, 83 cases) in this study. The intraoperative conditions and postoperative complications were compared between the 2 groups.

Results

In group A, the time of operation, postoperative first flatus, extubation, antibiotics, and discharge were shorter than in group B (t = -17.775, p = 0.000; t = -7.649, p = 0.000; t = -5.807, p = 0.000; t = -9.247, p = 0.000; t = -9.322, p = 0.000, respectively). Furthermore, intraoperative blood loss was less (t = -2.199, p = 0.029) and hospital costs were lower (t = -6.685, p = 0.000). However, there was no significant difference in postoperative complications between the 2 groups (p > 0.05).

Conclusions

In patients who meet the screening criteria, PDC without ENBD after LCBDE is safe and effective and worthy of clinical application.

Lessons learnt from the first 200 unselected consecutive cases of laparoscopic exploration of common bile duct stones at a district general hospital

BACKGROUND

The management of choledocholithiasis evolves with diagnostic imaging and therapeutic technology, facilitating a laparoscopic approach. We review our first 200 cases of laparoscopic exploration of the common bile duct, highlighting challenges and lessons learnt.

METHODS

We retrospectively studied the first 200 cases of laparoscopic cholecystectomy with common bile duct exploration between 2006 and 2019. The database contains demographics, clinicopathological characteristics, diagnostic modalities, operative techniques, duration and outcomes.

RESULTS

We compared two approaches: transcystic vs. transcholedochal in our 200 cases. Choledocholithiasis was suspected preoperatively in 163 patients. 21 cases found no stones. Of the remainder, 111/179 cases were completed via the transcystic route and the remaining were completed transcholedochally (68/179); 25% of the transcholedochal cases were converted from a transcystic approach. CBD diameter for transcystic route was 8.2 vs. 11.0 mm for transcholedochal. Total clearance rate was 84%. Retained or recurrent stones were noted in 7 patients. Length of stay was 5.8 days, 3.5 days in the transcystic route vs. 9.4 days after transcholedochal clearance. Eight patients required re-operation for bleeding or bile leak. No mortalities were recorded in this cohort, but 2 cases (1%) developed a subsequent CBD stricture.

CONCLUSION

Concomitant laparoscopic common bile duct clearance with cholecystectomy is feasible, safe and effective in a district general hospital, despite constraints of time and resources. The transcystic route has a lower complication rate and shorter hospital stay, and hence our preference of this route for all cases. Advancements in stone management technology will allow wider adoption of this technique, benefitting more patients.

Laparoscopic Exploration of the Common Bile Duct: A Systematic Review of the Published Evidence Over the Last 10 Years

INTRODUCTION

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

METHODS

A systematic review of the published evidence over the last decade that has looked into the outcomes of laparoscopic exploration of the common bile duct through transductal and transcystic approaches.

RESULTS

Our systematic review included 36 relevant papers. The majority were based on nonrandomized protocols conducted in single centers with high expertise. The data analysis showed that laparoscopic common bile duct exploration through both approaches was successful in more than 84% of the patients, with an average length of hospital stay of 5.6 days. Conversion to open surgery was reported in 5%-8% of the patients, and the bile leak rates from the more recent studies was 0%-12%, with mortality figures of 0%-1.3%. The outcomes were statistically in favor of the transcystic route when compared to the transductal route from the viewpoints of bile leak rates, mean operative time, duration of hospital stay and morbidity.

CONCLUSION

In experienced hands, both laparoscopic approaches in common bile duct exploration are safe in patients who are clinically fit to have this intervention. It is associated with a statistically significant lower overall morbidity and shorter duration of hospital stay when compared to open surgery. Relevant up-to-date high-quality randomized trials are unavailable.

Can T-tube drainage be replaced by primary suture technique in laparoscopic common bile duct exploration? A meta-analysis of randomized controlled trials

BACKGROUND

Although laparoscopic common bile duct exploration (LCBDE) is considered the best treatment and has the advantages of being minimally invasive for common bile duct (CBD) stones, the choice of T-tube drainage (TTD) or primary duct closure (PDC) after LCBDE is still controversial. Therefore, the aim of the study was to compare the superiority of PDC versus TTD after LCBDE for choledocholithiasis.

METHODS

All potential studies which compare the surgical effects between PDC with TTD were electronically searched for in PubMed, Web of Science, and the Cochrane library databases up to November 2019. Data synthesis and statistical analysis were carried out using RevMan 5.3 software.

RESULTS

In total, six randomized controlled trials with 604 patients (307 in the PDC group and 297 in the TTD group) were included in the current meta-analysis. As compared with the TTD group, the pooled data showed that PDC group had shorter operating time (WMD = -24.30; 95% CI = -27.02 to -21.59; p < 0.00001; I² = 0%; p < 0.88), less medical expenditure (WMD = -2255.73; 95% CI = -3330.59 to -1180.86; p < 0.0001; I² = 96%; p < 0.00001), shorter postoperative hospital stay (OR = -2.88; 95% CI = -3.22 to -2.54; p < 0.00001; I² = 60%; p < 0.03), and lower postoperative complications (OR = 0.49; 95% CI = 0.31 to 0.78; p = 0.77; I² = 0%; p = 0.003). There were no significant differences between the two groups concerning bile leakage (OR = 0.74; 95% CI = 0.36 to 1.53; p = 0.42; I² = 0%; p = 0.90) and retained stones (OR = 0.96; 95% CI = 0.36 to 2.52; p < 0.93; I² = 0%; p < 0.66).

CONCLUSIONS

LCBDE with PDC should be performed as a priority alternative compared with TTD for choledocholithiasis.

Primary Closure Versus T-Tube Drainage Following Laparoscopic Common Bile Duct Exploration in Patients With Previous Biliary Surgery

Laparoscopic common bile duct exploration (LCBDE) has been recently introduced for management of CBD stone in patients with previous biliary surgery history. The aim of this study was to evaluate the safety and effectiveness of primary closure in patients with previous biliary surgery history compared to T-tube drainage. Eighty patients with previous biliary surgery history including laparoscopic cholecystectomy, open cholecystectomy, or open common bile duct exploration were enrolled in the retrospective study. The patients were divided into 2 groups according to the methods of choledochotomy closure. Group A: patients with primary closure after LCBDE (n = 51); group B: patients with T-tube drainage after LCBDE (n = 29). Group A exhibited a shorter postoperative hospital stay and lower hospitalization expenses compared to group B. There was no significant difference in conversion rate to open surgery, operating time, intraoperative blood loss, bile leakage rate, overall complication rate, and stone recurrence rate between the 2 groups. Biliary stricture was not observed in the 2 groups during the follow-up period. Primary closure following LCBDE is safe and effective for the management of CBD stones in patients with previous biliary surgery history.

Laparoscopic Transcystic Common Bile Duct Exploration in the Emergency Is as Effective and Safe as in Elective Setting

BACKGROUND

Emergent laparoscopic transcystic common bile duct exploration (LTCBDE) has been reported to be on the increase in some institutions, reflecting the growing confidence with the technique. However, no study has focused on the outcomes of LTCBDE in the non-elective setting. The aim of this study is to investigate whether LTCBDE can be performed effectively and safely in the emergency.

METHODS

This is a retrospective study of 500 consecutive patients with choledocholithiasis subjected for LTCBDE at the Hospital Italiano de Buenos Aires from January 2009 to January 2018. Procedures were classified according to the setting as emergent or elective. Demographic data and perioperative parameters were compared between groups.

RESULTS

Throughout the period comprised, 500 patients were admitted for choledocholithiasis and gallstones. A single-step treatment combining LTCBDE and laparoscopic cholecystectomy was attempted: 211 (42.2%) were performed electively and the 289 (57.8%) as an emergency. There was no significant difference in the success rate of LTCBDE (93.9% versus 93.8%, p = 0.975) for the two groups. The operative time was slightly longer in the emergency group (122 ± 63 versus 106 ± 53 min, p = 0.002). Postoperative recovery was slower in the emergency group, as reflected by a higher rate of prolonged postoperative stay (21.1% vs 5.7%, p < .001). The rates of postoperative complications were similar between groups (2.8% vs 5.9%, p = 0.109).

CONCLUSION

Emergent LTCBDE can be performed with equivalent efficacy and morbidity when compared to an elective procedure. Patients undergoing emergent procedures have longer procedures and hospital stays.

Clinical role of frequency-doubled double-pulse neodymium YAG laser lithotripsy for removal of difficult biliary stones in laparoscopic common bile duct exploration

BACKGROUND

The optimal methods for patients with difficult biliary stones remain under debate. The aim of this study was to evaluate the role of frequency-doubled double-pulse neodymium YAG (FREDDY) laser lithotripsy for removing difficult biliary stones during laparoscopic common bile duct exploration (LCBDE).

METHODS

Between March 2013 and January 2015, 42 consecutive patients with difficult biliary stones who underwent LCBDE with FREDDY laser lithotripsy were included in this study. The clinical data of all patients were retrospectively collected and analysed.

RESULTS

Bile ducts were completely cleared in all patients. The complications related to laser lithotripsy were not noted. A total of 38 patients (90.5%) underwent primary closure of common bile duct, and T-tube drainage was applied to four patients (9.5%). No bile duct injury, bleeding and perforation were observed. There were no post-operative surgery-related deaths. Bile leakage occurred in four patients (9.5%) with primary closure procedure, and all of them were managed successfully with conservative therapy. The median follow-up period was 42.8 months, with no evidence of bile duct stricture and stone recurrence in all patients.

CONCLUSIONS

The LCBDE combined with FREDDY laser lithotripsy appear to be effective and safe for the treatment of difficult biliary stones.

How to choose the most appropriate technique for the single-stage treatment of cholecysto-choledocolithiasis?

Background

We utilized transcystic clearance and intra-operative papillotomy through a rendezvous technique for the treatment of cholecysto-choledocolithiasis. The goal of this study was to evaluate the reliability of pre-operative parameters to address the most suitable surgical procedure.

Methods

A total of 180 patients affected by calculi of the gallbladder and bile duct underwent the single-stage treatment. According to several pre-operative parameters, 141 patients had to supposedly undergo transcystic clearance of the bile duct, while 39 patients had to be treated with the rendezvous technique. All patients were treated with the sequential procedure: first, we tried the transcystic procedure and, if there was a failure, we used a rendezvous technique. We prospectively analysed each group based on a series of variables such as sex, age, operative time, success rate of proposed treatment, conversion rate, post-operative complications and hospital stay.

Results

Transcystic clearance was successful in 134 out of 141 patients (95.0%), while 2 patients needed to undergo a laparo-endoscopy procedure (failure). Thirty-five out of 39 patients (89.7%) obtained common bile-duct (CBD) clearance through the rendezvous technique, while 1 patient obtained clean-up through the simple transcystic procedure (failure). Five out of 141 patients with transcystic clearance and 3 out of 39 patients with the rendezvous technique underwent laparotomy CBD clearance with conversion rates of 3.5% and 7.7%, respectively. Post-operative complications showed similar percentages for both procedures. However, the surgical time turned out to be longer for the rendezvous technique.

Conclusions

The one-stage procedure for the treatment of cholecysto-choledocolithiasis was possible in 94% of the cases utilizing a surgical technique selected according to the patient’s case history. The pre-operative parameters, such as jaundice, CBD diameters and stone diameters, have certified their reliability as good predictors of the most suitable procedure to follow.

Surgical (Open and laparoscopic) management of large difficult CBD stones after different sessions of endoscopic failure: A retrospective cohort study

Objectives

For complicated common bile duct stones (CBDS) that cannot be extracted by endoscopic retrograde cholangiopancreatography (ERCP), management can be safely by open or laparoscopic CBD exploration (CBDE). The study aimed to assess these surgical procedures after endoscopic failure.

Methods

We analyzed 85 patients underwent surgical management of difficult CBDS after ERCP failure, in the period from 2013 to 2018.

Results

Sixty-seven (78.8%) and 18(21.2%) of our patients underwent single and multiple ERCP sessions respectively. An impacted large stone was the most frequent cause of ERCP failure (60%). Laparoscopic CBDE(LCBDE), open CBDE(OCBDE) and the converted cases were 24.7% (n = 21), 70.6% (n = 60), and 4.7% (n = 4) respectively. Stone clearance rate post LCBDE and OCBDE reached 95.2% and 95% respectively, Eleven (12.9%) of our patients had postoperative complications without mortality. By comparing LCBDE and OCBDE; there was a significant association between the former and longer operative time. On comparing, T-tube and 1ry CBD closure in both OCBDE and LCBDE, there was significantly longer operative time, and post-operative hospital stays in the former. Furthermore, in OCBDE group, choledocoscopy had an independent direction to 1ry CBD repair and significant association with higher stone clearance rate, shorter operative time, and post-operative hospital stay.

Conclusion

Large difficult CBDS can be managed either by open surgery or laparoscopically with acceptable comparable outcomes with no need for multiple ERCP sessions due to their related morbidities; furthermore, Open choledocoscopy has a good impact on stone clearance rate with direction towards doing primary repair that is better than T-tube regarding operative time and post-operative hospital stay.

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Large difficult CBD stones can be managed either by open surgery or laparoscopically with acceptable comparable outcomes.

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No need for multiple ERCP sessions due to their related morbidities.

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Open choledocoscopy has a good impact on stone clearance rate with direction towards doing primary repair.

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Primary repair is better than T-tube regarding operative time and post-operative hospital stay.

Surgical (Open and laparoscopic) management of large difficult CBD stones after different sessions of endoscopic failure: A retrospective cohort study

Objectives

For complicated common bile duct stones (CBDS) that cannot be extracted by endoscopic retrograde cholangiopancreatography (ERCP), management can be safely by open or laparoscopic CBD exploration (CBDE). The study aimed to assess these surgical procedures after endoscopic failure.

Methods

We analyzed 85 patients underwent surgical management of difficult CBDS after ERCP failure, in the period from 2013 to 2018.

Results

Sixty-seven (78.8%) and 18(21.2%) of our patients underwent single and multiple ERCP sessions respectively. An impacted large stone was the most frequent cause of ERCP failure (60%). Laparoscopic CBDE(LCBDE), open CBDE(OCBDE) and the converted cases were 24.7% (n = 21), 70.6% (n = 60), and 4.7% (n = 4) respectively. Stone clearance rate post LCBDE and OCBDE reached 95.2% and 95% respectively, Eleven (12.9%) of our patients had postoperative complications without mortality. By comparing LCBDE and OCBDE; there was a significant association between the former and longer operative time. On comparing, T-tube and 1ry CBD closure in both OCBDE and LCBDE, there was significantly longer operative time, and post-operative hospital stays in the former. Furthermore, in OCBDE group, choledocoscopy had an independent direction to 1ry CBD repair and significant association with higher stone clearance rate, shorter operative time, and post-operative hospital stay.

Conclusion

Large difficult CBDS can be managed either by open surgery or laparoscopically with acceptable comparable outcomes with no need for multiple ERCP sessions due to their related morbidities; furthermore, Open choledocoscopy has a good impact on stone clearance rate with direction towards doing primary repair that is better than T-tube regarding operative time and post-operative hospital stay.

Primary closure after laparoscopic common bile duct exploration is feasible for elderly patients: 5-Year experience at a single institution

OBJECTIVE

Laparoscopic common bile duct exploration (LCBDE) has been demonstrated safety and effective for patients with gallbladder stones and extrahepatic bile duct stones, however few studies reported its suitability for the treatment of elderly patients. Thus, our study aims to investigate the safety and feasibility of primary closure after LCBDE in the treatment of elderly patients.

METHODS

408 out of 499 patients with Gallbladder stones complicated with choledocholithiasis who were undergone LCBDE and primary closure were divided into two groups: Group A (<65 years old, n = 249) and Group B (≥65 years old, n = 159) and the related clinical data were compared and analyzed by statistical method.

RESULTS

Pre-operative American Society of Anesthesiologists (ASA) score of elderly patients was significantly higher than the younger patients (P < 0.05). In both groups, the positive rate of Choledocholithiasis and bile sludge at exploration, number of stones in CBD, utilization rate of Electro-hydraulic lithotripsy, estimated blood loss, successful duct clearance, the rate of postoperative bile leakage, postoperative bile duct stricture, reoperation, stone recurrence, and other postoperative complications showed no significant difference (p > 0.05). There were also no statistical differences between both groups in time to removal of drainage, postoperative hospital stay, readmission within 30 days and mortality (p > 0.05).

CONCLUSIONS

It is safe and feasible to treat the elderly patients with common bile duct stones under the premise of strict surgical indications, skilled laparoscopic procedures and accurate endoscopic suture techniques.

Human fibrin sealant reduces post-operative bile leakage of primary closure after laparoscopic common bile duct exploration in patients with choledocholithiasis

Context:

Primary closure of the common bile duct (CBD) without drainage is considered a suitable approach after laparoscopic CBD exploration (LCBDE); however, the risk of post-operative bile leakage is high. Up to now, it has not been clear whether human fibrin sealant can reduce post-operative bile leakage of the primary suture.

Aims:

In this study, we evaluated the role of human fibrin sealant in primary closure of the CBD after LCBDE.

Subjects and Methods:

Patients with choledocholithiasis who had undergone primary duct closure of the CBD after LCBDE were divided into two groups according to whether fibrin sealant was used.

Statistical Analysis Used:

Fisher's exact test or the Chi-square test was used for categorical variables to calculate frequencies and percentages between the groups. The Student's t-test was used to compare the means of the continuous variables between the groups.

Results:

The human fibrin sealant group had a lower rate of post-operative bile leakage compared to the other group (P < 0.05). There were no significant differences in additional parameters such as operative time, post-operative stay duration, time to drain removal, bile duct stenosis, acute allergic reaction and overall mortality.

Conclusions:

Human fibrin sealant can reduce post-operative bile leakage in primary closure of CBD after LCBDE in patients with choledocholithiasis.

The reasonable drainage option after laparoscopic common bile duct exploration for the treatment of choledocholithiasis

OBJECTIVE

To obtain a reasonable drainage after laparoscopic common bile duct exploration (LCBDE) for the treatment of choledocholithiasis.

METHODS

Data of 350 consecutive patients who underwent LCBDE in our hospital from January 2014 to December 2016 were retrospectively reviewed. All the patients were divided into three groups according to different drainage types after LCBDE, including T-tube group with 116 cases, primary closure (PC) group with 114 cases and stent insertion group with 120 cases. Operative parameters and outcomes were compared.

RESULTS

The operative time was no significant difference between the T-tube group (106.71 ± 5.19 min), PC group (105.46 ± 5.77 min) and stent insertion group (106.88 ± 5.91 min) (F = 2.175, P = 0.115). The postoperative hospital stay was significantly shorter in the stent insertion group (5.62 ± 0.70 d) than in the T-tube group (7.79 ± 0.85 d) and PC group (7.60 ± 0.80 d) (F = 279.649, P = 0.000). The hospitalization cost was significantly less in the stent insertion group (19,432.78 ± 661.74 yuan) than in the T-tube group (22,059.90 ± 697.98 yuan) and PC group (21,927.20 ± 772.02 yuan) (F = 512.492, P = 0.000). The incidence of postoperative biliary-specific complications was 2.59% (3/116 cases) in the T-tube group, 2.63% (3/114 cases) in the PC group, and 0% (0/120 cases) in the stent insertion group, but this difference was not statistically significant (χ² = 3.177, P = 0.204). The return to normal levels of postoperative liver function tests (LFTs) was significantly faster in the stent insertion group and T-tube group than in the PC group (P < 0.05). The number of 314 patients were followed up for a median time of 20 months (range from 1-48 months), and no biliary stricture, cholangitis or stone recurrence occurred in these patients during that time.

CONCLUSIONS

Stent insertion shows better results when compared with T-tube drainage and primary duct closure in terms of postoperative hospital stay and hospitalization cost. It is the prior option for the choledochotomy closure after LCBDE in suitable patients.

Acute Pancreatitis After Laparoscopic Transcystic Common Bile Duct Exploration: An Analysis of Predisposing Factors in 447 Patients

INTRODUCTION

In laparoscopic transcystic common bile duct exploration (LTCBDE), the risk of acute pancreatitis (AP) is well recognized. The present study assesses the incidence, risk factors, and clinical impact of AP in patients with choledocholithiasis treated with LTCBDE.

METHODS

A retrospective database was completed including patients who underwent LTCBDE between 2007 and 2017. Univariate and multivariate analyses were performed by logistic regression.

RESULTS

After exclusion criteria, 447 patients were identified. There were 70 patients (15.7%) who showed post-procedure hyperamylasemia, including 20 patients (4.5%) who developed post-LTCBDE AP. Of these, 19 were edematous and one was a necrotizing pancreatitis. Patients with post-LTCBDE AP were statistically more likely to have leukocytosis (p < 0.004) and jaundice (p = 0.019) before surgery and longer operative times (OT, p < 0.001); they were less likely to have incidental intraoperative diagnosis (p = 0.031) or to have biliary colic as the reason for surgery (p = 0.031). In the final multivariate model, leukocytosis (p = 0.013) and OT (p < 0.001) remained significant predictors for AP. Mean postoperative hospital stay (HS) was significantly longer in AP group (p < 0.001).

CONCLUSION

The risk of AP is moderate and should be considered in patients with preoperative leukocytosis and jaundice and exposed to longer OT. AP has a strong impact on postoperative HS.

Success of intraoperative imaging and management of suspected choledocholithiasis without pre-operative bile duct imaging - A case series

Background

Laparoscopic common bile duct exploration (LCBDE) is gaining popularity over endoscopic retrograde cholangiopancreatography (ERCP) for the management of common bile duct stones. However, its application has been almost exclusively following preoperative stone confirmation via magnetic retrograde cholangiopancreatography (MRCP), endoscopic ultrasound (EUS) or ERCP. We present our series of LCBDE following detection of common bile duct stones with intraoperative imaging (IOI) alone, in consecutive elective and emergency patients with suspected choledocholithiasis.

Materials and methods

All patients with suspected but unconfirmed choledocholithiasis undergoing LC with intention to proceed to LCBDE between January 2015 and June 2017 were included. LCBDE was performed following the discovery of choledocholithiasis on IOI.

Results

371 patients with suspected choledocholithiasis underwent LC with IOI. CBD stones or obstructing sludge was identified in 107 patients (29%), with sensitivity of 96.2% and specificity of 98.5%. 100 patients, median age 59, went on to have LCBDE as indicated by intraoperative imaging. 76% were performed as emergency cases and conversion to open rate was 2%. There were no mortalities. Bile leak and retained stones occurred in 4% and 3% respectively. 7/100 patients required re-intervention, with re-look laparoscopy (n = 4) and ERCP (n = 3). Median length of stay was 1.5 and 3 days for elective and emergency cases respectively, and 30 readmission rate was 8%.

Discussion and conclusion

Traditionally patients presenting with suspicion of choledocholithiasis undergo preoperative MRCP/EUS and/or ERCP prior to eventual LC. We propose an alternative, more streamlined, pathway of treatment without requiring preoperative cholangiography, applicable to both elective and emergency patients.

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Laparoscopic common bile duct exploration is a safe and effective treatment for bile duct stones.

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Intraoperative cholangiography is sensitive and specific in identification of bile duct stones.

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Bile duct exploration can be safely performed on the basis on intraoperative imaging alone.

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Intraoperative imaging provides sufficient information for real time decision making.

Learning curve for performing choledochotomy bile duct exploration with primary closure after laparoscopic cholecystectomy

BACKGROUND

Primary closure after laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration (LCBDE) is a safe and effective approach for treating cholecystolithiasis with choledocholithiasis. The aim of this study was to evaluate the learning curve of performing primary closure after LC+LCBDE.

METHODS

We retrospectively identified all patients who underwent primary closure after LC+LCBDE performed by a single surgeon from January 2009 to April 2015 in our institution, and analyzed preoperative, intraoperative, and postoperative data using the cumulative sum (CUSUM) analysis to evaluate the learning curve for this procedure.

RESULTS

Overall, there were 390 patients. The total postoperative complications rate was 7.2%, including bile leakage in 9 (2.3%) patients and retained common bile duct stone in 3 (0.8%) patients. The CUSUM operating time (OT) learning curve was best modeled by the equation: CUSUM_OT = 312.209 × procedure^0.599 × e^{(-0.011×procedure)} + 122.608 (R² = 0.96). The learning curve was composed of two phases, phase 1 (the initial 54 patients) and phase 2 (the remaining 336 patients). A significant decrease in the OT (116.8 ± 22.4 vs. 93.8 ± 17.8 min; p < 0.001) and complication rate (16.7 vs. 5.7%; p < 0.01) including the rate of bile leakage (7.4 vs. 1.5%; p < 0.01) and retained stone (3.7 vs. 0.3%; p < 0.01) was observed between the two phases. In addition, 20 patients had conversion to open surgery. Impacted stones were independently associated with conversion, as indicated by a multivariable analysis.

CONCLUSION

The data suggest that the learning curve of this procedure was achieved in approximately 54 cases. An impacted stone was the only risk factor that affected the conversion rate.

Single-stage procedure for the treatment of cholecysto-choledocolithiasis: a surgical procedures review

While laparoscopic cholecystectomy is generally accepted as the treatment of choice for simple gallbladder stones, in cases in which common bile duct stones are also present, clinical and diagnostic elements, along with intraoperative findings, define the optimal means of treatment. All available options must be accessible to the surgical team which must necessarily be multidisciplinary and include a surgeon, an endoscopist, and a radiologist in order to identify the best option for a truly personalized surgery. This review describes the different techniques and approaches used based on distinctive recommendations and factors, according to the specific cases treated and the results achieved.

Laparoscopic Exploration Can Salvage Recurrent Common Bile Duct Stone after Cholecystectomy

Conventionally, patients suffered from recurrent common bile duct (CBD) stone after cholecystectomy are suggested to be treated with endoscopic retrograde cholangiopancreaticography. This study was designed to explore the feasibility of laparoscopic common bile duct exploration (LCBDE) as a salvage procedure for recurrent CBD calculi after cholecystectomy. A retrospective review was conducted of data from 65 patients who underwent LCBDE for recurrent CBD calculi after cholecystectomy from January 2011 to July 2015. LCBDE was successfully carried out in 61 cases, with a successful rate of 93.8 per cent. Three cases required open conversion because of serious abdominal adhesion, and one case for intraoperative bleeding. Postoperative bile leakage occurred in two cases, and bile peritonitis developed in one case; all these three patients with complications were fully cured by conservative treatment. A postoperative retained CBD stone was found in one patient, which was extracted with endoscopic sphincterotomy. Furthermore, it was found that the mean operative time and length of postoperative hospital stay were much shorter in primary closure group (n = 49) than in T-tube drainage group (n = 12), and the hospital expense was also lower in primary closure group. We suggest that LCBDE could be a novel approach as a salvage procedure for the recurrent CBD stone after cholecystectomy, and we prefer to intraoperative primary closure of CBD if possible.

Retrospective Clinical Study of the Effects of T-Tube Placement for Bile Duct Stricture

Background

T-tube placement in the common bile duct (CBD) is a surgical alternative to bile duct reconstruction in cholecystectomy for cholecysto-choledocholithiasis, or gallstones. The aim of this retrospective clinical study was to investigate the incidence of late complications of T-tube placement.

Material/Methods

Retrospective review identified 35 patients who had T-tube placement during cholecystectomy. Clinical data were collected on surgical indications, patient demographics, and clinical symptoms. Ultrasound (US) was used measure the diameter of the common bile duct (CBD), intrahepatic ducts, and presence or absence of stones in the CBD. Data from laboratory investigations included the aspartate aminotransferase-to-platelet ratio index (APRI), which was used as a non-invasive method to evaluate both cholestasis and liver fibrosis.

Results

Of the 35 patients included in the study, 33 (94.3%) underwent open cholecystectomy, CBD exploration, and T-tube placement due to cholecysto-choledocholithiasis. The remaining two patients (5.7%) underwent primary CBD repair and T-tube placement secondary to CBD injury. The mean follow-up period after T-tube placement was 69 months. In patients with T-tube placement, the CBD diameters ranged from 4–21 mm, were normal in 20 patients (57.1%), dilated in 15 patients (42.9%), with the mean CBD diameter being 8.91±4.82 mm. No residual or recurrent CBD calculus and no clinical or laboratory evidence of cholangitis or cholestasis were found.

Conclusions

A retrospective clinical study at a single surgical center, showed that T-tube placement during open cholecystectomy and CBD exploration was a safe procedure that did not result in late complications.

Safety and efficacy of a novel continuous incision technique for laparoscopic transcystic choledocholithotomy

INTRODUCTION

The purpose of this study was to evaluate the safety and efficacy of a novel continuous incision technique for the cystic duct and the bile duct over the orifice for laparoscopic transcystic choledocholithotomy (LTCL).

METHODS

LTCL was attempted in 103 consecutive patients from January 1998 to March 2015 and was successful in 96 patients. The cystic duct confluence was made by cutting upward from the orifice in 19 patients. The cystic duct was incised downward beyond the orifice to the bile duct in the other 77 patients. Both of these procedures involved LTCL.

RESULTS

LTCL was successful in 96 patients. It failed in seven patients because of large bile duct stones (BDS), left lateral entry of the cystic duct, or the cystic duct's small diameter. The success rates of LTCL were 98% (47/48), 96% (42/44), and 64% (7/11) for patients with BDS <10 mm, 10-20 mm, and ≥20 mm, respectively. The success rate for removing BDS <20 mm was significantly higher than the removal rate for BDS ≥20 mm (P < 0.0001). There was no significant difference between the incidences of complications associated with BDS ≥10 mm and with BDS <10 mm (P = 0.49). In those who underwent successful LTCL, complications occurred in 3 of 23 patients with failed preoperative duodenoscopic sphincterotomy and in 9 of the other 73 patients; the incidence of complications did not significantly differ between these groups (P = 0.93).

CONCLUSION

LTCL is safe and feasible for exploration of the bile duct and removal of BDS <20 mm.

Five hundred consecutive laparoscopic common bile duct explorations: 5-year experience at a single institution

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) has gained wide popularity in the treatment of choledocholithiasis. Bile leakage remains a major cause of postoperative morbidity. The aim of this study was to report 5-year results of 500 LCBDEs and identify risk factors associated with bile leakage.

METHODS

Five hundred consecutive LCBDEs performed in one institution from September 2011 to June 2016 were reviewed. Patients' clinical data were retrospectively collected and analyzed. Univariable and multivariable analysis of bile leakage was performed by logistic regression.

RESULTS

We found stones (n = 388) or bile sludge (n = 71) in 459 patients (92%) on exploration, leaving 41 patients (8%) without stones. Operative time was 128 min in the first 250 LCBDEs, and this decreased to 103 min in the second 250 LCBDEs (P = 0.0004). Four hundred and eight (82%) procedures were completed with primary closure after choledochotomy; the rate of primary closure increased significantly in the second 250 patients compared with the first (88 vs 76%; P = 0.0005), whereas T-tube placement (2 vs 6%; P = 0.0225) and transcystic approach (7 vs 12%; P = 0.0464) decreased, respectively. Stone clearance was successful in 495 patients (99%). Overall morbidity was 5%, and bile leakage occurred in 17 patients (3.4%). Two patients died from bile leakage. The median follow-up was 24 months with stone recurrence occurred in two patients and bile duct stricture in one patient. Univariable analysis identified diameter of the common bile duct (CBD), stone clearance, and T-tube insertion as risk factors related to bile leakage. Multivariable analysis taking these three factors into account identified non-dilated CBD (risk ratio (RR) = 9.87; P = 0.007) and failure in stone clearance (RR = 11.88; P = 0.024) as significant risk factors.

CONCLUSIONS

Bile leakage following LCBDE is associated with diameter of the CBD and stone clearance. LCBDE would be safer in proficient laparoscopic surgeons with a careful selection of patients.

A survey of European-African surgeons' management of common bile duct stones

BACKGROUND

Common bile duct (CBD) stones can be managed by either endoscopic retrograde cholangiopancreatography (ERCP) or laparoscopic common bile duct exploration (LCBDE). The aim of this survey was to document the management of CBD stones by European-African HPB Association (E-AHPBA) members.

METHODS

All 331 members of the E-AHPBA were invited by personal email to participate to an online survey.

RESULTS

Ninety-three (28%) surgeons replied within 2 months. Responding surgeons were attending surgeons (84%), working as HPB surgeons (75%) in academic hospitals (73%). In patients with clinically suspected CBD stones, MRCP was the preferred diagnostic test for 61% of respondents. LCBDE was the preferred therapeutic strategy for 11 (12%) respondents only. Previous gastric surgery was an absolute contraindication to ERCP for 47% of respondents. Absence of CBD dilation was considered an absolute contraindication for LCBDE in 24% of respondents. Yearly caseload exceeded 10 patients for only 30% of 56 centers performing LCBDE. The transcystic approach was preferred by 39% of surgeons performing LCBDE. There was considerable variation amongst respondents with regard to type and duration of drainage, bile duct closure technique and follow-up after LCBDE.

CONCLUSION

Indications for single-stage LCBDE are not standardized and do not appear well established across E-AHPBA members.

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.

Primary Closure Following Laparoscopic Common Bile Duct Reexploration for the Patients Who Underwent Prior Biliary Operation

To assess feasibility of primary closure following laparoscopic common bile duct reexploration for the patients who underwent prior biliary operation, we retrospectively studied 50 patients with recurrent or residual common bile duct (CBD) stones who underwent laparoscopic biliary reoperation between June 2008 and June 2013. Endoscopic sphincterotomy (EST) was treated for all these patients and validated failed. They were divided into two groups. Primary closure following laparoscopic common bile duct exploration (LCBDE) was performed in 25 cases (group A); LCBDE plus T-tube drainage was performed in others (group B). The items of operation were compared. The duration of the operation in group A was shorter than that in group B (141 ± 85 vs 158 ± 71 min, p < 0.05), as was postoperative hospital stay (16 ± 2.3 vs 23 ± 2.3 h, p < 0.05) and the times of postoperative gastrointestinal function recovery (16 ± 2.3 vs 23 ± 2.3 h, p < 0.05). Just one duodenum was damaged in group B. Postoperative clinically significant bile leakage occurred in two patients in group A and one case in group B. The median follow-up was 18 months. No postoperative pancreatitis, postoperative bleeding, bile peritonitis after T-tube removal, stricture of bile duct, and death occurred in the two groups. Just two cases in group B were verified residual stones after 1 month. Primary closure following laparoscopic common bile duct reexploration for the patients who underwent prior biliary operation appears to be a minimally invasive, safe, feasible, and effective procedure when done by expert laparoscopic surgeons.

Laparoscopic Common Bile Duct Exploration: 9 Years Experience from a Single Center

Introduction

The aim of the study was to evaluate the safety and feasibility of laparoscopic common bile duct exploration (LCBDE) through cholangiotomy with T-tube placement in one séance for common bile duct stones (CBDS).

Methods

Between January 2005 and December 2010, a total of 99 patients with CBDS stones undergoing LCBDE with T-tube insertion at Enköping Hospital, Sweden, were registered prospectively. All patients were followed up by review of the patient records according to a standardized protocol.

Results

No severe intraoperative complications were registered. Four procedures required conversion to open cholecystectomy due to impacted stones or technical difficulty. The mean operative time was 194 min [(SD) 57 min]. The mean postoperative hospital stay was 4.8 days, SD 2.4 days. At secondary cholangiography, 2 (2%) retained stones were found. Two (2%) patients had minor bile leakage, which resolved spontaneously. None of the patients experienced biliary peritonitis, biliary fistula, pancreatitis, or cholangitis. No death within 30 days after surgery was seen. No patient was readmitted with clinical signs of stricture.

Conclusion

If performed by a surgeon familiar with the technique, LCBDE is a safe and feasible alternative for managing CBDS. The advantages are most pronounced in the case of multiple and large CBDS. The risk for retained stones and stricture is low.

Long-term Outcome of Primary Closure After Laparoscopic Common Bile Duct Exploration Combined With Choledochoscopy

BACKGROUND

Primary closure after laparoscopic common bile duct exploration (LCBDE) is considered to be a safe alternative to T-tube drainage on the basis of the short-term outcome. However, little published data exist regarding the biliary complications at the long-term follow-up of primary closure versus T-tube drainage following LCBDE. Hence, the aim of this study is to assess the long-term outcome of primary closure after LCBDE.

MATERIALS AND METHODS

This is a retrospective study of 142 consecutive patients who underwent LCBDE combined with choledochoscopy for CBD stones. After LCBDE, the choledochotomy was closed by primary closure (group P) in 91 patients (64.1%) and with T-tube drainage (group T) in 51 patients (35.9%). The data on operative outcome and long-term biliary complications were compared between the 2 groups.

RESULTS

The mean operation time was significantly shorter in group P than group T (168.9 ± 50.1 min for group P vs. 198.0 ± 59.6 min for group T, P = 0.002). The hospital stay was significantly shorter in group P than in group T (8.59 ± 6.0 d for group P vs. 14.96 ± 5.4 d for group T, P = 0.001). Postoperative bile leak occurred in 2 patients (2.2%) in group P and 1 patient (2.0%) in group T. With a mean follow-up of 48.8 months, the stone recurrence rate in group P and group T were 4.4% and 5.9%, respectively (P = 0.722). During the follow-up period, there was no sign of biliary stricture or other biliary complications in both groups.

CONCLUSIONS

The long-term follow-up data on primary closure after LCBDE indicated a low incidence of recurrent stones, and no biliary strictures. Thus, primary closure after LCBDE with choledochoscopy is considered to be a safe and effective alternative to T-tube drainage in terms of long-term outcome.

Eleven years of primary closure of common bile duct after choledochotomy for choledocholithiasis

BACKGROUND

The choice of surgical technique to extract stones from the common bile duct (CBD) depends on local experience, anatomical characteristics and also on the size, location and number of stones. Most authors consider choledochotomy an alternative to failed transcystic exploration, although some use it exclusively. Although the CBD is traditionally closed with T-tube drainage after choledochotomy, its use is associated with 11.3-27.5 % morbidity. This study examined the efficacy of laparoscopic CBD exploration (LCBDE) with primary closure for the treatment of CBD stones using intraoperative cholangiography (IOC).

METHODS

Retrospective study of 160 patients who underwent LCBDE with primary closure after choledochotomy between January 2001 and December 2012.

RESULTS

The diagnosis of choledocholithiasis was definitively made in all cases by IOC. The overall complication rate was 15 % and the biliary complication rate was 7.5 %. Bile leakage was reported in 11 patients (6.8 %). In over half the cases (63.6 %), no further action was required and the leak closed spontaneously. Six patients were reoperated (3.75 %), two for bile peritonitis and four for haemoperitoneum. The success rate for stone clearance was 96.2 %. The mortality rate and CBD stricture rate were 0 %.

CONCLUSION

Primary closure after choledochotomy to clear stones from the CBD is a safe technique that confers excellent results and allows one-stage treatment.

Systematic review with meta-analysis of studies comparing primary duct closure and T-tube drainage after laparoscopic common bile duct exploration for choledocholithiasis

BACKGROUND

With advances in laparoscopic instrumentation and acquisition of advanced laparoscopic skills, laparoscopic common bile duct exploration (LCBDE) is technically feasible and increasingly practiced by surgeons worldwide. Traditional practice of suturing the dochotomy with T-tube drainage may be associated with T-tube-related complications. Primary duct closure (PDC) without a T-tube has been proposed as an alternative to T-tube placement (TTD) after LCBDE. The aim of this meta-analysis was to evaluate the safety and effectiveness of PDC when compared to TTD after LCBDE for choledocholithiasis.

METHODS

A systematic literature search was performed using PubMed, EMBASE, MEDLINE, Google Scholar, and the Cochrane Central Register of Controlled Trials databases for studies comparing primary duct closure and T-tube drainage. Studies were reviewed for the primary outcome measures: overall postoperative complications, postoperative biliary-specific complications, re-interventions, and postoperative hospital stay. Secondary outcomes assessed were: operating time, median hospital expenses, and general complications.

RESULTS

Sixteen studies comparing PDC and TTD qualified for inclusion in our meta-analysis, with a total of 1770 patients. PDC showed significantly better results when compared to TTD in terms of postoperative biliary peritonitis (OR 0.22, 95% CI 0.06-0.76, P = 0.02), operating time (WMD, -22.27, 95% CI -33.26 to -11.28, P < 0.00001), postoperative hospital stay (WMD, -3.22; 95% CI -4.52 to -1.92, P < 0.00001), and median hospital expenses (SMD, -1.37, 95% CI -1.96 to -0.77, P < 0.00001). Postoperative hospital stay was significantly decreased in the primary duct closure with internal biliary drainage (PDC + BD) group when compared to TTD group (WMD, -2.68; 95% CI -3.23 to -2.13, P < 0.00001).

CONCLUSIONS

This comprehensive meta-analysis demonstrates that PDC after LCBDE is feasible and associated with fewer complications than TTD. Based on these results, primary duct closure may be considered as the optimal procedure for dochotomy closure after LCBDE.

Laparoscopic Choledocholithotomy With a Novel Articulating Forceps

PURPOSE

The aim of this study was to assess the safety and effectiveness of laparoscopic common bile duct (CBD) exploration with a novel articulating forceps.

METHODS

A retrospective analysis was carried out of 90 patients who underwent laparoscopic transcholedochal CBD exploration for choledocholithiasis between May 2006 and June 2014. Forty-five patients underwent laparoscopic choledocholithotomy using the routine instruments (group A). Forty-five patients underwent laparoscopic choledocholithotomy using the routine instruments plus the novel articulating forceps (group B). The 2 group populations were similar with regard to demographic data and clinical presentations.

RESULTS

Laparoscopic transcholedochal CBD exploration was successful in all 90 patients. The mean diameter of the CBD was 14.42 mm in group A and 14.73 mm in group B (P > .05). The average number of stones extracted per patient was 4.22 in group A and 4.67 in group B (P > .05). The patients in group A had a significantly longer operative time than the patients in group B (109.38 vs 80.49 minutes; P < .01). The intraoperative blood loss was minimal in both groups, and no major complications were observed in either group. The mean hospitalization stay was 6.60 days in group A and 5.58 days in group B (P < .01).

CONCLUSION

Laparoscopic transcholedochal CBD exploration with the novel articulating forceps is a safe and effective approach to the management of choledocholithiasis that offers a short operating time and short postoperative hospital stay.