Laparoscopic common bile duct exploration plus cholecystectomy versus endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for cholecystocholedocholithiasis: a meta-analysis. Surg Endosc. 2019;33:3275-3286. [PMID: 30511313 DOI: 10.1007/s00464-018-06613-w]

Clinical application of ERCP concurrent laparoscopic cholecystectomy in the treatment of cholecystolithiasis complicated with extrahepatic bile duct stones

Objective

To compare the clinical efficacy of endoscopic retrograde cholangiopancreatography (ERCP) combined with laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration and lithotomy (LCBDE) in the treatment of cholecystolithiasis combined with bile duct stones.

Methods

From September 2018 to January 2022, 195 patients with cholecystolithiasis complicated with extrahepatic bile duct stones from Department of Department of General Surgery, Shanghai Jiading Central Hospital met the inclusion criteria, including 60 cases in the LC group and 86 cases in the LCBDE group. The general condition, operation success rate, complications and residual stone rate of the two groups were retrospectively analyzed.

Results

In the simultaneous operation group, 58 patients successfully performed ERCP, and the indwelling rate of the abdominal drainage tube (41.7 % vs. 95.3 %) was significantly better than that in the LCBDE group. There was no significant difference in the conversion rate to open surgery, operation time, and intraoperative blood loss between the two groups. In the simultaneous surgery group, 4 patients (6.7 %) developed pancreatitis after ERCP, which was cured by conservative treatment. The pain score at 6 h after operation was significantly lower than that in the LCBDE group (3.9 ± 1.6 vs 6.5 ± 2.4). There were no significant differences in biliary leakage (1.7 % vs. 4.7 %), postoperative cholangitis (5.0 % vs. 5.8 %), incision infection (3.3 % vs. 3.5 %), and bile duct stone residue rate (5.0 % vs 3.5 %) between the two groups. There was no severe pancreatitis, second operation or death. The duration of hospital stay was shortened in the concurrent operation group (5.1 ± 2.3d vs 7.9 ± 3.7d), and the operation cost was significantly higher than that in the LCBDE group (48839.9 ± 8549.5 vs 34635.9 ± 5893.7 yuan).

Conclusion

ERCP combined with LC and LCBDE are both safe and effective methods for the treatment of cholecystolithiasis combined with extrahepatic bile duct stones. The simultaneous operation group has certain advantages in patient comfort and rapid rehabilitation, which can be popularized in qualified units.

Comparison of laparoscopic common bile duct exploration plus cholecystectomy and endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy for elderly patients with common bile duct stones and gallbladder stones

BACKGROUND

Common bile duct (CBD) stones commonly occur in cholecystectomy cases. The management options include laparoscopic CBD exploration (LCBDE) or endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). Although ERCP is fully developed, it has complications, and LCBDE is a proven alternative. This study aimed to evaluate the safety and efficacy of these treatments in elderly individuals aged ≥70 years.

METHODS

A retrospective study between January 2015 and July 2022 included 160 elderly patients (aged ≥70 years) diagnosed with cholelithiasis and choledocholithiasis. The patients were divided into 1-stage (LCBDE [n = 80]) or 2-stage (ERCP followed by LC [n = 80]) treatment groups. Data collected encompassed comorbidities, symptoms, bile duct clearance, postoperative complications, and long-term outcomes for systematic analysis.

RESULTS

This study analyzed 160 patients treated for CBD stones, comparing 1-stage and 2-stage groups. The 1-stage group had more female patients than the 2-stage group (57.5% vs 37.5%, respectively). The 1-stage group had a mean age of 80.55 ± 7.00 years, which was higher than the mean age in the 2-stage group. American Society of Anesthesiologists classification, Charlson Comorbidity Index, and laboratory findings were similar. Pancreatitis and cholangitis occurred after ERCP in the 2-stage group. Stone clearance rates (92.35% [1-stage group] vs 95.00% [2-stage group]) and biliary leakage incidence (7.5% [1-stage group] vs 3.0% [2-stage group]) were similar, as were postoperative complications and long-term recurrence rates (13.0% [1-stage group] vs 12.5% [2-stage group]).

CONCLUSION

Our research indicates that both the combination of LCBDE and LC and the sequence of ERCP followed by LC are equally efficient and secure when treating CBD stones in elderly patients. Consequently, the 1-stage procedure may be considered the preferred treatment approach for this demographic.

Comparison of 1-stage and 2-stage Managements for Common Bile Duct Stones and Gallstones (CBDS): A Retrospective Study

OBJECTIVE

The aim of this study was to evaluate the efficacy, safety, and surgical outcomes of 2-stage management, namely preoperative endoscopic retrograde cholangiopancreatography (ERCP) + laparoscopic cholecystectomy (ERCP+LC) or LC + postoperative ERCP (LC+ERCP), as well as 1-stage management, LC + laparoscopic common bile duct exploration (LCBDE) for treating patients with gallstones and common bile duct stones (CBDS).

METHODS

This retrospective study analyzed the data of 180 patients with common bile duct stones (CBDS) who were admitted to the Department of General Surgery at Tongji Hospital, Tongji University, between January 2019 and June 2021. The study included 3 groups: ERCP+LC (group 1), LC+ERCP (group 2), and LC+LCBDE (group 3), each consisting of 60 patients. Clinical metrics of the patients were collected and compared among the groups.

RESULTS

Group 3 had the shortest operation duration and hospital stay compared with group 1 and group 2. In addition, group 3 had the lowest long-term postoperative complications, particularly the recurrence rate of CBDS. The total cost was also the lowest in group 3. Furthermore, patients in group 3 had the lowest postoperative amylase levels. All patients in the study achieved successful stone clearance. There were no significant differences in the conversion to other procedures rate, postoperative alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, and mortality among the three groups (P > 0.05).

CONCLUSIONS

Both 1-stage management and 2-stage management are effective treatments for CBDS. The LC+LCBDE management is a safe treatment option, offering shorter hospital stays and operation duration, lower costs, and fewer complications.

Pragmatic algorithm for management of common bile duct calculi in resource-limited settings in India

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) facilitates the removal of common bile duct (CBD) calculi by endoscopy. When ERCP fails, exploration of CBD is required for the clearance of CBD calculi. The optimum way for the exploration of CBD is by choledochoscopy. Dedicated flexible or rigid choledochoscopes are expensive and available only in few places in India. Since 1991, we subjected patients with suspected CBD calculi to ERCP, followed by laparoscopic cholecystectomy (LC). Patients in whom ERCP failed to clear CBD were subjected to open exploration of CBD using any easily available, suitable, straight rigid scope for choledochoscopy.

PATIENTS AND METHODS

Since March 1991, out of 8866 patients with cholelithiasis, 862 underwent ERCP. Ninety-six patients in whom ERCP failed to clear CBD underwent open exploration of CBD. In each case of exploration of CBD, choledochoscopy was performed using a straight rigid scope, either a cystoscope, paediatric cystoscope, hysteroscope or 5-mm laparoscopy telescope with a 5-mm cannula.

RESULTS

The CBD clearance was complete in 95 patients, and one patient had an impacted calculus at the ampulla. CBD explorations were followed by choledochoduodenostomy, T-tube placement or suturing of choledochotomy. No residual calculi were observed after such exploration.

CONCLUSION

From our results, we advocate the following algorithm for CBD calculi in resource-limited settings. Subject patients with CBD calculi to ERCP followed by LC. In case of failed ERCP, open exploration of CBD with choledochoscopy using any suitable rigid scope. Dedicated flexible or rigid choledochoscope is not essential. This approach is cost-effective and successful.

Laparoscopic common bile duct exploration: what factors determine success?

BACKGROUNDS

Laparoscopic common bile duct exploration (LCBDE) has been shown to be effective in managing choledocholithiasis whilst avoiding ERCP-related complications. However, patient and technical factors effects outcome. This study aimed to explore the matters effecting the failure of LCBDE.

METHODS

All patients who underwent a laparoscopic cholecystectomy (LC) between 2007 and 2021 were identified using a prospective database. Data were collected for patients who underwent LCBDE including demographics, pre-operative investigations, intra-operative findings, technique of bile duct clearance and clearance rates, and post-operative outcomes. Predictors of failed LCBDE were identified.

RESULTS

Laparoscopic cholecystectomy was performed in 3648 patients. Of these, 374 underwent LCBDE for suspected choledocholithiasis. Choledochoscopy was most frequently used (58.8%) with a success rate of 84.1%. Small cystic duct diameter (4.7 vs. 3.4 mm, P = 0.002), stone size >6 mm (P = 0.02), stone: cystic duct ratio >1 (P = 0.04), and >3 stones was associated with failed LCBDE by univariate analysis. Small cystic duct diameter (OR: 0.45, 95% CI: 0.26-0.77, P = 0.004) and stone size >6 mm (OR: 0.23, 95% CI: 0.06-0.92), P = 0.04) correlated with failure by multivariate analysis. Failed LCBDE was associated with increased length of stay (6.6 days vs. 3.1 days, P = 0.001), however the rate of serious complications or mortality was unaffected.

CONCLUSION

LCBDE is safe and effective in managing choledocholithiasis. Factors such as cystic duct diameter, size and number of CBD stones, and stone: cystic duct ratio are associated with increased likelihood of inadequate clearance. The presence of these factors can help clinicians in decision making during LCBDE to improve chance of success.

Endoscopic ultrasound avoids diagnostic ERCP among the ASGE high-risk group - Experience in an Asian population

BACKGROUND

A prediction system for common bile duct (CBD) stones was originally published by the American Society for Gastrointestinal Endoscopy (ASGE) in 2010 and was last revised in 2019. We wanted to investigate its application in an Asian population, who have different etiologies of bile duct stone formation and accessibility to medical service compared to the West.

METHODS

This is a single center retrospective study. Patients who received endoscopic ultrasound (EUS) for suspected CBD stones were collected from our endoscopic record system over a 10-year period. The accuracy of the revised ASGE criteria was estimated according to the results of EUS. A minimum follow-up of 6 months was required to detect false negative results.

RESULTS

142 patients were enrolled, 87 (61%) patients had CBD stones. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of the revised ASGE criteria for high-risk patients were 69%, 38%, 64%, 44%, and 57%. 36% of the ASGE-defined high-risk patients negative for CBD stones on EUS. The two significant predictors for CBD stone were CBD dilatation (adjusted OR 3.06, 95% C.I. 1.31-7.17, p = 0.010) and ascending cholangitis (adjusted OR 2.28, 95% C.I. 1.01-5.15, p = 0.047).

CONCLUSION

ASGE recommends that patients defined as high-risk for choledocholithiasis be considered for direct ERCP without prior need for confirmation imaging. However, our findings indicate a high rate (36%) of patients in that group negative for CBD stones on EUS. Hence, EUS is still be suggested first in selective high-risk patients so that diagnostic ERCP can be avoided in our Asian society.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Novel technique for laparoscopic common bile duct exploration using flexible videobronchoscope to study on clinical outcomes of single-stage (laparoscopic cholecystectomy and laparoscopic common bile duct exploration) versus dual-stage (endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy) for cholelithiasis with choledocholithiasis - Prospective study in a tertiary care centre (BRACE study - BRonchoscope Assisted Common bile duct Exploration Study)

INTRODUCTION

This study aimed to study on clinical outcomes of single-stage (laparoscopic cholecystectomy [LC] and laparoscopic common bile duct [CBD] exploration using flexible videobronchoscope) versus dual-stage (endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy) for cholelithiasis with choledocholithiasis-prospective study in a tertiary care centre (BRACE STUDY-Bronchoscope-Assisted CBD Exploration [CBDE] Study).

PATIENTS AND METHODS

Between April 2022 and April 2023, patients who underwent LC with laparoscopic CBDE and endoscopic retrograde cholangiopancreatography (ERCP) followed by LC participated in this single-centre prospective research. The Institute Ethics Committee granted its approval after receiving an ethical review. The primary endpoint of the proposed research was the removal of the gall bladder and CBD stones. The secondary outcomes studied were complications using the Clavien-Dindo score, cost-effectiveness, patient satisfaction score and post-procedure duration of hospital stay.

RESULTS

A total of 168 patients were included in the study. The success rate of LC with laparoscopic CBD exploration using a flexible videobronchoscope (Group 1) was significantly higher as compared to ERCP f/b LC (Group 2) (96.4% vs. 84.5%, P value = 0.02). Out of the 84 patients in Group 1, direct choledochotomies were performed on 83 of them. Group 1 had a considerably shorter hospital stay (4.6 ± 2.4 vs. 5.3 ± 6.2 days; P = 0.03). Both the cost (P = 0.002) and the number of procedures per patient (P < 0.001) were considerably higher in Group 2. Major complications (Clavien-Dindo grade 3 and above) were significantly higher in Group 2 (P = 0.04). Patient satisfaction in Group 1 scored more favourably than those in Group 2 (2.26 ± 0.3 vs. 1.92 ± 0.7; P = 0.006).

CONCLUSION

For concurrent gall bladder and CBD stones, single-stage management by LCBDE using a flexible videobronchoscope has a significantly better primary outcome and lower major complications than dual-stage management. The single-stage strategy also has advantages in terms of a shorter hospital stay, the need for fewer procedures, cost efficiency and patient satisfaction.

The Laparoscopy in Biliary Exploration Research and Training Initiative (LIBERTI) trial: simulator-based training for laparoscopic management of choledocholithiasis

BACKGROUND

Laparoscopic cholecystectomy with common bile duct exploration (LCBDE) is equivalent in safety and efficacy to endoscopic retrograde cholangiopancreatography (ERCP) plus laparoscopic cholecystectomy (LC) while decreasing number of procedures and length of stay (LOS). Despite these advantages LCBDE is infrequently utilized. We hypothesized that formal, simulation-based training in LCBDE would result in increased utilization and improve patient outcomes across participating institutions.

METHODS

Data was obtained from an on-going multi-center study in which simulator-based transcystic LCBDE training curricula were instituted for attending surgeons and residents. A 2-year retrospective review of LCBDE utilization prior to LCBDE training was compared to utilization up to 2 years after initiation of training. Patient outcomes were analyzed between LCBDE strategy and ERCP strategy groups using χ2, t tests, and Wilcoxon rank tests.

RESULTS

A total of 50 attendings and 70 residents trained in LCBDE since November 2020. Initial LCBDE utilization rate ranged from 0.74 to 4.5%, and increased among all institutions after training, ranging from 9.3 to 41.4% of cases. There were 393 choledocholithiasis patients analyzed using LCBDE (N = 129) and ERCP (N = 264) strategies. The LCBDE group had shorter median LOS (3 days vs. 4 days, p < 0.0001). No significant differences in readmission rates between LCBDE and ERCP groups (4.7% vs. 7.2%, p = 0.33), or in post-procedure pancreatitis (0.8% v 0.8%, p > 0.98). In comparison to LCBDE, the ERCP group had higher rates of bile duct injury (0% v 3.8%, p = 0.034) and fluid collections requiring intervention (0.8% v 6.8%, p < 0.009) secondary to cholecystectomy complications. Laparoscopic antegrade balloon sphincteroplasty had the highest technical success rate (87%), followed by choledochoscopic techniques (64%).

CONCLUSION

Simulator-based training in LCBDE results in higher utilization rates, shorter LOS, and comparable safety to ERCP plus cholecystectomy. Therefore, implementation of LCBDE training is strongly recommended to optimize healthcare utilization and management of patients with choledocholithiasis.

The Safety and Cost Analysis of Outpatient Laparoendoscopy in the Treatment of Cholecystocholedocholithiasis: A Retrospective Study

INTRODUCTION

The advantages of single-stage treatment of cholecystocholedocholithiasis are well established, but the conditions for carrying out treatment on an outpatient basis require a review of concepts and practices of medical corporations.

OBJECTIVE

To evaluate the practice of treating cholecystocholedocholithiasis by laparoendoscopy on an outpatient basis with cost analysis.

METHOD

A retrospective study was conducted on patients with cholecystocholedocholithiasis treated by combined laparoscopic cholecystectomy and endoscopic choledocholithotomy from January 2015 to January 2019. After collecting data from physical and digital medical records, the patients were divided into two groups-AR (n = 42)-ambulatory regimen and HR (n = 28)-hospitalization regimen-which were compared in terms of demographic, clinical and treatment variables and their results, as well as in terms of costs.

RESULTS

The mean age of the AR group was lower than that of the HR group and the physical status of the AR patients was better when assessed according to the American Society of Anesthesiologists (ASA) (p = 0.01). There was no difference between groups regarding the risk of choledocholithiasis (p = 0.99). For the AR group, the length of stay was shorter: 11.29 h × 65.21 h (p = 0.02), as was the incidence of postoperative complications assessed by applying the Clavien-Dindo classification: 3 (7.1%) × 11 (39.2%) (p < 0.01). The total mean costs were higher for the HR group (USD 2489.93) than the AR group (USD 1650.98) (p = 0.02).

CONCLUSION

Outpatient treatment of cholecystocholedocholithiasis by laparoendoscopy is safe and viable for most cases, has a lower cost and can support the reorientation of training and practice of hepatobiliary surgeons.

Current Operative Approaches to the Diseased Gallbladder. Diagnosis and Management Updates for General Surgeons

Cholecystitis is a common diagnosis which requires management by general surgeons. Morbidity from cholecystitis is often life-threatening, especially in patients with underlying liver cirrhosis or other medical comorbidities. Diagnosis and management of this disease can vary among providers and hospitals. The decision to utilize a radiological or endoscopic temporizing maneuver in severe acute cholecystitis and the timing of later definitive cholecystectomy are relevant points of discussion within general surgery societies. In the last 5 years, the use of intraoperative ductal imaging by conventional vs fluorescence cholangiography had gained significant interest due to the widespread availability of indocyanine green. Finally, the operative strategies and how to manage intra-/postoperative complications are very important to optimizing patient outcomes. In this review paper, we discuss all treatment aspects of cholecystitis and provide updates in its management.

Risk factors for post‑retrograde cholangiopancreatography pancreatitis in patients with common bile duct stones: A meta‑analysis

Endoscopic retrograde cholangiopancreatography (ERCP) has become a common treatment method for common bile duct stones. However, ERCP is also associated with a high risk of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). Identification of risk factors is essential for reducing the incidence of PEP. The present study aimed to summarize the risk factors for PEP by performing a meta-analysis. Therefore, studies published between 2000 and 2022 were screened in PubMed, Cochrane Library, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang Digital Periodicals and the Weipu Database, with no language restrictions. Newcastle-Ottawa Scale was used to assess the quality of the included studies. Stata 17.0 software was utilized for the meta-analysis of 14 possible risk factors. Overall, 15 high-quality studies were included into the present meta-analysis. The results showed that female [odds ratio (OR), 1.42; 95% CI, 1.23-1.64), age <60 years (OR, 1.53; 95% CI, 1.06-2.21), difficult intubation (OR, 4.87; 95% CI, 2.73-8.68), ≥3 cannulation attempts (OR, 9.64; 95% CI, 4.16-22.35), cannulation time ≥10 min (OR, 2.37; 95% CI, 1.67-3.35), history of pancreatitis (OR, 2.95; 95% CI, 1.06-5.51), pancreatic duct visualization (OR, 3.63; 95% CI, 2.47-5.34) and sphincter of Oddi dysfunction (OR, 5.72; 95% CI, 1.80-18.24) are potential risk factors for PEP (P<0.05). In conclusion, the present meta-analysis suggests that PEP can be affected by several risk factors, particularly the technique-related factors such as the frequency and time of cannulation. Therefore, effective precautions should be taken as early as possible to reduce the incidence of PEP.

Single-operator cholangioscopy system for management of acute cholecystitis secondary to choledocholithiasis

This study aimed to investigate the safety and efficacy of endoscopic retrograde cholangiopancreatography (ERCP) + EyeMax (single-operator cholangioscopy system; SOC) (i.e., ERCP+SOC) for the treatment of choledocholithasis-associated acute cholecystitis. Twenty-five patients were evaluated between January 2022 and June 2023. The success rate (technical + clinical), procedure time, postoperative recovery, postoperative length of hospital stay, and complications rates were recorded. The procedure and clinical success rates were 92% (23/25) and 96% (24/25), respectively. The mean procedure time was 36.6±10 minutes (standard deviation [SD]). The average postoperative hospitalization was 2±0.8 days. No adverse events such as bleeding, perforation, or bile leakage occurred. Cholecystitis did not recur during the 2 to 18 months of follow-up. ERCP+SOC may be a feasible, safe, and effective alternative treatment for acute cholecystitis secondary to choledocholithiasis. ERCP+SOC was able to simultaneously resolve both biliary tract and gallbladder problems via natural orifice endoscopy. Its advantages included no skin wound, reduced postoperative pain, quick recovery, limited to no exposure to x-rays, and a short hospital stay.

Choledocholithiasis: A Review of Management and Outcomes in a Regional Setting

Background Choledocholithiasis is a common surgical presentation with an incidence of 8% to 16% in symptomatic cholelithiasis. Treatment often requires a multi-stage approach via endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC), which can prolong the length of stay (LoS) and expose patients to unnecessary risks. A single-stage procedure, such as LC with common bile duct exploration (CBDE), is a safe and effective option that may decrease LoS. This study compares patient outcomes and management in a regional center and aims to identify factors that predict the presence of confirmed choledocholithiasis. Methods A retrospective cross-sectional analysis was performed on all patients admitted to Toowoomba Hospital for management of diagnosed or suspected choledocholithiasis from January 2021 to March 2023. Patient demographics, ERCP findings, and operative data were collated. Results A total of 195 patients were identified, including 136 patients undergoing multi-stage management, 34 patients who had an ERCP alone, and 25 patients who underwent single-stage management. Single-stage procedures had an 80% success rate with an average LoS of 3.6 days. Multi-stage procedures had an average LoS of 8.1 days and an ERCP success rate of 93%. Complication rates between ERCP (11.7%) and LC with CBDE (9.7%) were comparable. Time to index ERCP and serum bilirubin level were found to be significantly lower in those with positive index ERCP findings compared to those without. Conclusion Single-stage procedures are a safe way to manage choledocholithiasis and are associated with a reduced LoS when compared to multi-stage management, with comparable efficacy and morbidity rates.

Ultrasound-Guided Percutaneous Transhepatic Cholangioscopic Lithotripsy for the Treatment of Common Bile Duct Stones and Analysis of Risk Factors for Recurrence

BACKGROUND

As a minimally invasive treatment for common bile duct (CBD) stones, ultrasound-guided percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) is gaining attention and recognition from the medical community.

METHODS

A retrospective analysis was conducted on patients with CBD stones treated in our hospital from January 2016 to April 2022. Patients were divided into three groups: 77 treated with PTCSL, 93 with endoscopic retrograde cholangiopancreatography (ERCP), and 103 with laparoscopic common bile duct exploration (LCBDE). Their clinical data, perioperative indicators, and complications were analyzed comparatively. Then, risk factors for the post-PTCSL recurrence of CBD stones were analyzed by logistic regressions. Finally, the receiver operating characteristic curve was drawn.

RESULTS

All perioperative indicators of the PTCSL group were better than the LCBDE group (P < 0.001). The incidences of cholangitis, hemobilia, and incisional infection after surgery were lower in the PTCSL group than in the LCBDE group (P < 0.05). Pancreatitis, reflux esophagitis, and papillary stenosis occurred less frequently in the PTCSL group than in the ERCP group (P < 0.05). Logistic regression analysis indicated that gallstones and family history were independent risk factors. The AUC for recurrent CBD stones predicted by multi-indicators was 0.895 (95% CI 0.792-0.999, P < 0.001) with a sensitivity of 96.7% and specificity of 68.8%.

CONCLUSIONS

Ultrasound-guided PTCSL is a safe and effective treatment for CBD stones. Patients recovered quickly with fewer postoperative complications. It can be a first-line treatment for CBD stones. Gallstones and family history are independent risk factors for recurrent CBD stones, which provide a reference for clinicians in identifying the high-risk population needing close follow-up.

Delay for cholecystectomy after common bile duct clearance with ERCP is just running after recurrent biliary event

BACKGROUND

Gallstone disease will affect 15% of the adult population with concomitant common bile duct stone (CBDS) occurring in up to 30%. Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay of management for removal of CBDS, as cholecystectomy for the prevention of recurrent biliary event (RBE). RBE occurs in up to 47% if cholecystectomy is not done. The goal of this study was to evaluate the timing of occurrence of RBE after common bile duct clearance with ERCP and associated outcomes.

METHODS

The records of all patients who underwent ERCP for gallstone disease followed by cholecystectomy, in a single center from 2010 to 2022, were reviewed. All RBE were identified. Actuarial incidence of RBE was built. Patients with and without RBE were compared.

RESULTS

The study population is composed of 529 patients. Mean age was 58.0 (18-95). There were 221 RBE in 151 patients (28.5%), 39/151 (25.8%) having more than one episode. The most frequent RBE was acute cholecystitis (n = 104) followed by recurrent CBDS (n = 95). Median time for first RBE was 34 days. Actuarial incidence of RBE started from 2.5% at 7 days to reach 53.3% at 1 year. Incidence-rate of RBE was 2.9 per 100 person-months. Patients with RBE had significant longer hospitalisation time (11.7 vs 6.4 days; P < 0.0001), longer operative time (66 vs 48 min; P < 0.0001), longer postoperative stay (2.9 vs 0.9 days; P < 0.0001), higher open surgery rate (7.9% vs 1.3%; P < 0.0001), and more complicated pathology (23.8% vs 5.8%; P < 0.0001) and cholecystitis (64.2% vs 25.9%; P < 0.0001) as final diagnoses.

CONCLUSIONS

RBE occurred in 28.5% of the subjects at a median time of 34 days, with an incidence of 2.5% as early as 1 week. Cholecystectomy should be done preferably within 7 days after common bile duct clearance in order to prevent RBE and adverse outcomes.

ERCP findings provide further justification for a "surgery-first" mindset in choledocholithiasis

INTRODUCTION

Choledocholithiasis is most often managed in a two-procedure pathway including endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). In contrast, a single-stage, surgery-first approach consisting of LC, cholangiogram, and laparoscopic common bile duct exploration (LCBDE) is associated with reduced hospital stays and equivalent morbidity. Despite this, nationwide referral patterns heavily favor ERCP, obscuring those undergoing ERCP with obstructions amenable to simple intraoperative interventions. We hypothesized that most patients had endoscopic findings consistent with simple sludge or small-to-medium stones, which could have been cleared by basic LCBDE maneuvers.

METHODS

We retrospectively reviewed 294 patients > 18 years old who underwent preoperative ERCP for the management of suspected choledocholithiasis. Exclusion criteria included: failed ERCP, cholangitis, prior cholecystectomy, patient refusal of surgery, or medical conditions precluding surgical candidacy. Stone size was categorized as small (0-4 mm), medium (5-7 mm), and large (≥ 8 mm).

RESULTS

At the time of ERCP, 37 (20.1%) patients had sludge only, 96 (52.2%) had stones only, 42 (22.8%) had sludge and stones, and 9 (4.8%) had no stones. Of the 138 patients with any stones, 37 (26.8%) had small stones, 41 (29.7%) medium, 43 (31.2%) large, and 17 (12.3%) had uncharacterizable stones. Overall, 74.3% of patients had findings of sludge, stones (0-7 mm), or negative ERCP.

CONCLUSION

The majority of patients who underwent preoperative ERCP for suspected choledocholithiasis had findings that are amenable to simple intraoperative interventions. In fact, over a quarter of the patients had a negative ERCP, sludge, or small stones which would likely be cleared by flushing/glucagon precluding any further instrumentation. While large stones may require more advanced techniques, this represents a small percentage of patients. Surgery-first management for suspected choledocholithiasis can offer an efficient alternative for the majority of patients.

Laparoscopic Cholecystectomy in Children: The Experience of Two Centers Focusing on Indications and Timing in the Era of "New Technologies"

BACKGROUND

In children, laparoscopic cholecystectomy (LC) is now considered the gold standard for gallbladder (GB) removal. In the past, hemolytic disorders associated with cholelithiasis represented the most frequent conditions requiring LC; this is being overtaken by cholelithiasis and biliary conditions in overweight or ex-premature children.

AIMS

This study aims to describe current indications and timing for LC in pediatric patients.

METHODS

Retrospective study. Data on previous medical therapy, ultrasound, pre- and intraoperative aspects, and histology were collected for patients treated in 2020-2023.

RESULTS

In total, 45 patients were enrolled: 15 who underwent urgent surgery and 30 electives. Groups differed in terms of obesity rate, symptoms, ultrasound features, and intraoperative status. The most relevant risk factors for surgical complexity were age and pubertal stage, elevated cholestasis indexes, and gallbladder wall thickness > 3 mm at ultrasound. GB wall thickening ≥3 mm, US Murphy sign, fluid collections, and gallbladder distention on ultrasound correlated with high surgical scores.

CONCLUSIONS

Indications for laparoscopic cholecystectomy in children seem to evolve caused by changing characteristics of the pediatric population. Patients with overweight/obesity may develop more complex GB diseases. Asymptomatic patients should be considered for surgery after observation, considering age and/or pubertal maturation when other risk factors are absent.

Incidence, clinical features, and risk factors for acute pancreatitis following posterior instrumented fusion surgery for lumbar degenerative disease: a single-center, retrospective analysis of 20,929 patients

PURPOSE

The aim of this study is to identify the incidence, clinical features, and risk factors for postoperative acute pancreatitis (PAP) after lumbar surgery.

METHODS

We retrospectively analyzed patients who developed PAP after posterior lumbar fusion surgery. For each PAP patient, data were collected for four controls who underwent procedures in the same period and did not develop PAP. Statistical methods included univariate and multivariate analyses.

RESULTS

Totally, 21 out of 20,929 patients were diagnosed with PAP (0.10%) after posterior lumbar fusion surgery. Patients with degenerative lumbar scoliosis were at higher risk of developing PAP (P < 0.05). With atypical clinical features, PAP occurred within 3 days (0-5) after surgery. PAP patients had significantly higher incidence of osteoporosis (47.6 vs. 22.6%, P = 0.030) and fusion of L1/2(42.9 vs. 4.3%, P = 0.010), lower albumin (42.2 ± 4.1 vs. 44.3 ± 3.2 g/L, P = 0.010), more fusion segments (median 4 vs. 3, P = 0.022), larger surgical invasiveness index (median 9 vs. 8, P = 0.007), longer operation duration (232 ± 109 vs. 185 ± 90 min, P = 0.041), greater estimated blood loss (median 600 vs. 400 mL, P = 0.025), lower intraoperative mean arterial pressure (87.2 ± 9.9 vs. 92.1 ± 8.8 mmHg, P = 0.024). Multivariate logistic regression analysis found three independent risk factors: fusion of L1/2, surgical invasiveness index > 8, and intraoperative mean arterial pressure < 90 mmHg. All patients were treated with conservative therapy and fully recovered after 8.1 (4-22) days.

CONCLUSION

The incidence of PAP following posterior surgery for degenerative lumbar disease was 0.10%, and its clinical features were not typical. The fusion of L1/2, high surgical invasiveness index, and low intraoperative mean arterial pressure were independent risk factors for PAP after surgery for lumbar degenerative disease.

Evidence-based clinical practice guidelines for cholelithiasis 2021

The Japanese Society of Gastroenterology first published evidence-based clinical practice guidelines for cholelithiasis in 2010, followed by a revision in 2016. Currently, the revised third edition was published to reflect recent evidence on the diagnosis, treatment, and prognosis of cholelithiasis conforming to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Following this revision, the present English version of the guidelines was updated and published herein. The clinical questions (CQ) in the previous version were reviewed and rearranged into three newly divided categories: background questions (BQ) dealing with basic background knowledge, CQ, and future research questions (FRQ), which refer to issues that require further accumulation of evidence. Finally, 52 questions (29 BQs, 19 CQs, and 4 FRQs) were adopted to cover the epidemiology, pathogenesis, diagnosis, treatment, complications, and prognosis. Based on a literature search using MEDLINE, Cochrane Library, and Igaku Chuo Zasshi databases for the period between 1983 and August 2019, along with a manual search of new information reported over the past 5 years, the level of evidence was evaluated for each CQ. The strengths of recommendations were determined using the Delphi method by the committee members considering the body of evidence, including benefits and harms, patient preference, and cost-benefit balance. A comprehensive flowchart was prepared for the diagnosis and treatment of gallbladder stones, common bile duct stones, and intrahepatic stones, respectively. The current revised guidelines are expected to be of great assistance to gastroenterologists and general physicians in making decisions on contemporary clinical management for cholelithiasis patients.

A Retrospective Study on the Three-Port Technique of Laparoscopic Common Bile Duct Exploration for the Management of Cholelithiasis and Choledocholithiasis

Background

Laparoscopic cholecystectomy (LC) with laparoscopic common bile duct exploration (LCBDE) is convenient in treating cholelithiasis and choledocholithiasis due to its advantage of accelerated recovery. This retrospective study aimed to summarize the experience of cholelithiasis and choledocholithiasis treatment via three-port approach of LCBDE in Eastern China.

Methods

Patients diagnosed with cholelithiasis and choledocholithiasis between July 2019 and October 2021 were included. Patients who received LC+LCBDE+primary suturing of the common bile duct (CBD) via a three-port approach were assigned to the LCBDE-P group, and those who received LC+LCBDE+T-tube drainage of CBD comprised the LCBDE-T group. The measurement data were compared between the two groups. P-values <0.05 indicated statistical significance.

Results

A total of 88 patients were divided into two groups: LCBDE-P (n=50) and LCBDE-T (n=38). Multiple logistic regression analysis showed that LCBDE-P is associated with a shorter length of stay (OR=0.115, 95% CI: 0.040-0.329, P<0.001) and lower hospitalization costs (OR=0.120, 95% CI: 0.041-0.357, P<0.001). No significant differences between the two groups were detected in the operation time, intraoperative hemorrhage, clearance rate of CBD stones, postoperative liver function, and postoperative complications (P>0.05).

Conclusion

The three-port approach of LCBDE is a safe and feasible strategy for managing cholelithiasis and choledocholithiasis. Compared to LCBDE-T, LCBDE-P reduces the length of hospital stay and medical costs during hospitalization.

Laparoscopic common bile duct exploration with primary closure could be safely performed among elderly patients with choledocholithiasis

BACKGROUND

For patients with choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) is preferred over open surgery. Whether primary closure of the common bile duct (CBD) should be performed upon completion of choledochotomy remains unclear, and the corresponding indications for primary closure of the common bile duct have yet to be fully identified. This study was performed to evaluate the safety and feasibility of primary closure of CBD among elderly patients (≥ 70 years) after LCBDE.

METHODS

Patients with choledocholithiasis who had undergone LCBDE with primary closure of the CBD between July 2014 and December 2020 were retrospectively reviewed. Included patients were assigned into two groups (Group A: ≥70 years and Group B: <70 years) according to age. Group A was compared with Group B in terms of preoperative characteristics, intraoperative results and postoperative outcomes.

RESULTS

The mean operative time for Group A was 176.59 min (± 68.950), while the mean operative time for Group B was 167.64 min (± 69.635) (P = 0.324). The mean hospital stay after surgery for Group A was 8.43 days (± 4.440), while that for Group B was 8.30 days (± 5.203) (P = 0.849). Three patients in Group A experienced bile leakage, while bile leakage occurred in 10 patients in Group B (3.8% vs. 4.5%, P = 0.781). Group A was not significantly different from Group B in terms of postoperative complications and 30-day mortality except pneumonia (P = 0.016), acute cardiovascular event (P = 0.005) and ICU observation (P = 0.037). After a median follow-up time of 60 months, 2 patients in Group A and 2 patients in Group B experienced stone recurrence (2.5% vs. 0.9%, P = 0.612). One patient in Group A experienced stenosis of the CBD, while stenosis of the CBD occurred in 5 patients in Group B (1.3% vs. 2.2%, P = 0.937).

CONCLUSIONS

Primary closure of CBD upon completion of LCBDE could be safely performed among patients ≥ 70 years.

Primary suture for patients of bile duct stones after laparoscopic biliary tract exploration: a retrospective cohort study

There are still many physicians who are reluctant to use primary biliary suture in Laparoscopic common bile duct exploration (LCBDE) for fear of more complications. We compare and analyze the clinical effectiveness of bile duct primary suture with three laparoscopic ports and indwelling T-tube drainage (with four laparoscopic ports) in patients with choledocholithiasis after LCBDE. Clinical data of 135 patients with common bile duct (CBD) stone were compared, including general conditions, postoperative hospital stay, postoperative complications, hospitalization costs, postoperative follow-up and other indicators. Forty-eight patients underwent primary suture of bile duct (group A) and 87 were treated with external T-tube drainage (group B). There were no significant differences between the two groups neither relating to the age, gender, BMI, diameter of CBD, number of stones, preoperative bilirubin value, number of previous surgeries in preoperative, nor the operation time, residual stones, the number of cases converted from laparoscopic conversion to laparotomy. The postoperative complications like fever, bleeding, incision infection, bile duct stricture has no differences between two group. The incidence of bile leakage (p = 0.008) and postoperative electrolyte disturbance (p = 0.001) were slightly lower in group A. There were fewer postoperative complications in group A vs group B (p = 0.04). Patients in group A experienced shorter postoperative hospital stay (p < 0.001), earlier postoperative extubation (p < 0.001), lower total hospitalization costs (p = 0.03), and earlier postoperative recovery (p = 0.000). Primary suture of CBD is a safe and effective method for some patients after LCBDE.

The efficacy and safety of laparoscopic common bile duct exploration and cholecystectomy for the treatment of difficult common bile duct stones combined with gallstones: a multicenter retrospective study

PURPOSE

To analyze the benefits of laparoscopic common bile duct exploration and laparoscopic cholecystectomy (LCBDE + LC) versus endoscopic retrograde cholangiopancreatography and/or endoscopic sphincterotomy following laparoscopic cholecystectomy (ERCP/EST + LC) for difficult common bile duct stones combined with gallstones.

METHODS

A retrospective analysis of consecutive patients with difficult common bile duct stones combined with gallstones in three hospitals from January 2016 to January 2021 was performed.

RESULTS

ERCP/EST + LC contributed to reducing postoperative drainage time. However, LCBDE + LC showed a higher rate of complete clearance, along with lower postoperative hospital stays, expenses and incidence of postoperative hyperamylasemia, pancreatitis, re-operation and recurrence. In addition, LCBDE + LC showed safe and feasible performance in the elderly and patients with previous upper abdominal surgery.

CONCLUSION

It is an effective and safe method for LCBDE + LC for difficult common bile duct stones combined with gallstones.

Echo-Endoscopy Combined with Virtual Reality: A Whole Perspective of Laparoscopic Common Bile Duct Exploration in Children

Introduction: Endoscopic procedures are performed more frequently in children due to technological advances that can be safely performed in an adequate setting with a support of a multidisciplinary team. Pediatric indications for ERCP (endoscopic retrograde cholangiopancreatography) and EUS (endoscopic ultrasound) occur mainly due to congenital malformations. In a pediatric case series, we report the application of EUS combined with duodenoscopy, eventually associated with ERCP and minimally invasive surgery, highlighting the importance of defining a tailored dedicated management pathway for each patient. Patients and methods: A series of 12 patients, managed at our Center in the last three years, were evaluated, and their management was discussed. Results: EUS was performed in eight patients and permitted the differential diagnosis of duplication cysts and the visualization of the biliary tree and pancreatic anatomy. ERCP was attempted in five patients: in one case, it permitted the preservation of pancreatic tissue, postponing surgery and in three patients, it was technically unfeasible. MIS (minimally invasive surgery) was performed in seven patients, two with laparoscopic common bile duct exploration (LCBDE). Precise anatomical definition and the possibility of surgical simulation and team sharing were evaluated under VR HMD (Virtual Reality Head Mounted Display) in four cases. Conclusions: Exploration of the common bile duct in children differs from that of the adult population and combines echo-endoscopy and ERCP. The integrated use of minimally invasive surgery in the pediatric area is necessary for the whole management perspective in complex malformations and small patients. The introduction in the clinical practice of a preoperative study with Virtual Reality allows a better survey of the malformation and a tailored treatment.

How to perform laparoscopic common bile duct exploration through a transverse choledochotomy

This article reviews common bile duct stones and describes our technique of laparoscopic common bile duct exploration (LCBDE) through a transverse choledochotomy at Hawke's Bay Hospital, New Zealand.

Laparoscopic Common Bile Duct Clearance, is It Feasible and Safe After Failed Endoscopic Retrograde Cholangiopancreatography?

Introduction: Concomitant gallstones and common bile duct (CBD) stones is a common problem, and there is still no consensus on the best approach in the management. Options include preoperative endoscopic retrograde cholangiopancreatography (ERCP), Laparoscopic cholecystectomy (LC) with CBD exploration, and LC with postoperative ERCP. Each option has its own limitations and complications. In this article, we assessed the feasibility of laparoscopic surgical clearance of the CBD after a failed ERCP, reasons for failure of endoscopic clearance in our cohort. We will discuss the management options after ERCP failure, the challenges, and the outcomes. Materials and Methods: We retrospectively reviewed all the cases of laparoscopic common bile duct exploration (LCBDE) performed in our hospital between April 2006 and January 2019. Two hundred cases were performed, 178 cases as a primary procedure while 22 were performed as a secondary procedure after failed ERCP. We have previously published data on the case series (PMID 33140155) and here explored the cases performed after failed ERCP as a secondary procedure. We analyzed demographics of patients, preoperative investigations, ERCP trials, and reasons for ERCP failure, operative approach, duration of operation, conversion rate, complications, and outcomes. Results: Twenty-two patients underwent a laparoscopic CBD clearance after failed ERCP. Sixteen of these were in the first 5 years of the study. Multiple attempts of ERCP were made in 7 patients (31.8%) and a single attempt in 15 patients. In 8 patients (32%), the duct was not accessible (failed cannulation) due to a variety of reasons. Nine patients had impacted stones larger than 1 cm, 4 patients had Mirrizi syndrome with concomitant large CBD stones, and 1 patient failed endoscopic clearance because of the large number of stones in the CBD. CBD clearance was successful in 19 patients (88%), 8 were completed by a transcystic approach and 14 by a transcholedochal approach. Postoperative length of stay was 12 (+10) days. One patient had an unplanned readmission within 30 days. One patient required reoperation for bleeding. Three patients developed recurrent stones and 1 developed a subsequent stricture. No mortalities were recorded. Conclusion: LCBDE is feasible and appears safe as a secondary procedure after failed ERCP. The new technologies and the advancement of surgical techniques will continue to improve success and reduce morbidity.

Incidence and management of choledocholithiasis on routine intraoperative cholangiogram: a 5-year tertiary centre experience

BACKGROUND

The incidence of choledocholithiasis on routine intraoperative cholangiogram (IOC) during cholecystectomy is approximately 12%. Cholecystectomy without IOC may lead to undiagnosed choledocholithiasis placing patients at risk of complications such as pancreatitis or cholangitis. This study aims to determine the incidence of choledocholithiasis intraoperatively as well as the associated risk factors and the methods of management.

METHODS

A retrospective observational analysis of all laparoscopic cholecystectomies with IOC at the Gold Coast Hospital and Health Service from 1 January 2016 to 2 December 2021 was carried out. Patient demographics, operative data and cholangiogram findings were collected from electronic medical systems.

RESULTS

A total of 3904 cholecystectomies were carried out over the study period. 3520 (90.1%) had an IOC, and 474 (13.4%) had positive IOC findings. 158 (33.3%) of the cases were managed intraoperatively with hyoscine butylbromide with or without intravenous glucagon followed by biliary tree flushing alone, 183 (38.6%) received transcystic bile duct exploration (TCBDE) with a success rate of 83% and 167 (35.2%) received endoscopic retrograde cholangiopancreatography (ERCP). Choledocholithiasis was incidental in 44 (9.28%) patients.

CONCLUSION

Incidental choledocholithiasis during routine IOC is not uncommon. Management predominantly includes intraoperative TCBDE or postoperatively via an ERCP. This study has not found reliable preoperative factors to predict choledocholithiasis based on preoperative clinical, radiological and biochemical factors. A small proportion of patients received preoperative endoscopic intervention, and the decision-making process requires further investigation.

Application of Intraoperative Fluorescence Imaging with Indocyanine Green in the Difficult Gallbladder: A Comparative Study between Indocyanine Green-Guided Fluorescence Cholangiography and Conventional Surgery

Background: In the difficult gallbladder, the rate of bile duct injury (BDI) remains high. To lessen iatrogenic biliary injury, we attempted to utilize indocyanine green (ICG)-guided fluorescence cholangiography during surgery to illuminate the extrahepatic biliary tract. Materials and Methods: According to admission criteria, 38 patients were diagnosed with difficult gallbladder and underwent percutaneous transhepatic gallbladder drainage (PTGBD). Consecutive patients who underwent ICG-assisted laparoscopic biliary surgery (n = 18, ICG group) or conventional laparoscopic biliary surgery (n = 20, white light [WL group) were enrolled in this study. ICG group received ICG fluorescent cholangiography via PTGBD tube during operation; 16 cases of laparoscopic cholecystectomy (LC) and 2 cases of LC plus laparoscopic common bile duct exploration (LC+LCBDE) were performed by fluorescent laparoscopy. In the WL group, 16 cases of LC, 1 case of laparoscopic subtotal cholecystectomy (LSC), and 3 cases of LC+LCBDE were performed under white light without ICG. Result: The biliary system was successfully established in the ICG group. Compared with the WL group, the anatomy of the Calot's triangle with severe abdominal adhesion or local inflammatory edema was more clearly displayed by fluorescence. Laparoscopic surgery was completed in both groups without conversion to laparotomy. There were no significant differences in surgery-related complications (P = .232) and postoperative hospital stay (P = .074) between the two groups. However, compared with the WL group, the ICG group had less intraoperative blood loss (P = .002) and shorter operation duration (P = .006). Conclusion: ICG fluorescence cholangiography has good clinical application value in the difficult gallbladder, which can avoid iatrogenic BDI, reduce surgery-related complications and intraoperative blood loss, and shorten the duration of surgery.

Outcomes following common bile duct exploration versus endoscopic stone extraction before, during and after laparoscopic cholecystectomy for patients with common bile duct stones

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) and endoscopic retrograde cholangiopancreatography (ERCP) are two methods of retrieving common bile duct (CBD) stones. The best method for CBD stone removal is debatable. The aim of this study was to compare outcomes following LCBDE and/or ERCP, including laparoscopic cholecystectomy.

METHODS

Data were collected retrospectively for patients undergoing LCBDE and/or ERCP at a single centre from 2008 to 2018. Patients were grouped by intention-to-treat (single-stage LCBDE, pre-operative-, intra-operative-, or post-operative ERCP) and eventual plan (surgical or endoscopic). Outcomes included complication rates (minor Clavien-Dindo 1/2, major Clavien-Dindo 3/4, non-biliary complications) and mortality.

RESULTS

Of 671 patients, 578 patients received LCBDE and 93 patients received ERCP as primary care. Endoscopic clearance had significantly higher complications and mortality compared to surgical clearance. On an intention-to-treat basis LCBDE had the lowest minor-, major- and non-biliary complications, and mortality (5.2%, 6.1%, 2.9% and 0.5%, respectively), whilst pre-operative ERCP the worst (39.6%, 27.1%, 29.2% and 8.3%, respectively) (p=<0.001). LCBDE and postERCP had similar major complications and mortality.

CONCLUSION

Surgical clearance of CBD stones was potentially safer than endoscopic clearance. Pre-operative ERCP had the worst outcomes. LCBDE and postERCP are likely to have similar short-term patient outcomes.

Multi-institutional expert update on the use of laparoscopic bile duct exploration in the management of choledocholithiasis: Lesson learned from 3950 procedures

BACKGROUND

Recently there has been a growing interest in the laparoscopic management of common bile duct stones with gallbladder in situ (LBDE), which is favoring the expansion of this technique. Our study identified the standardization factors of LBDE and its implementation in the single-stage management of choledocholithiasis.

METHODS

A retrospective multi-institutional study among 17 centers with proven experience in LBDE was performed. A cross-sectional survey consisting of a semi-structured pretested questionnaire was distributed covering the main aspects on the use of LBDE in the management of choledocholithiasis.

RESULTS

A total of 3950 LBDEs were analyzed. The most frequent indication was jaundice (58.8%). LBDEs were performed after failed ERCP in 15.2%. The most common approach used was the transcystic (63.11%). The overall series failure rate of LBDE was 4% and the median rate for each center was 6% (IQR, 4.5-12.5). Median operative time ranged between 60-120 min (70.6%). Overall morbidity rate was 14.6%, with a postoperative bile leak and complications ≥3a rate of 4.5% and 2.5%, respectively. The operative time decreased with experience (P = .03) and length of hospital stay was longer in the presence of a biliary leak (P = .04). Current training of LBDE was defined as poor or very poor by 82.4%.

CONCLUSION

Based on this multicenter survey, LBDE is a safe and effective approach when performed by experienced teams. The generalization of LBDE will be based on developing training programs.

The single-stage management of bile duct stones is underutilised: A prospective multicentre cohort study with a literature review

Backgrounds/Aims

Bile duct stones (BDS) can be managed either prior to laparoscopic cholecystectomy (LC) using endoscopic retrograde cholangiopancreatography (ERCP) or with laparoscopic bile duct exploration (LBDE) at the time of LC. The latter is underutilised. The aim of this study was to use the dataset of the previously performed CholeS study to investigate LBDE hospital volumes, LBDE-to-LC rates, and LBDE outcomes.

Methods

Data from 166 United Kingdom/Republic of Ireland hospitals were used to study the utilisation of LBDE in LC patients.

Results

Of 8,820 LCs performed, 932 patients (10.6%) underwent preoperative ERCP and 256 patients (2.9%) underwent LBDE. Of the 256 patients who underwent LBDE, 73 patients (28.5%) had undergone prior ERCP and 112 patients (43.8%) had undergone prior magnetic resonance cholangiopancreatography. Fifteen (9.0%) of the 166 included hospitals performed less than five LBDEs in the two-month study period. LBDEs were mainly performed by upper gastrointestinal surgeons (84.4%) and colorectal surgeons (10.0%). Eighty-seven percent of the LBDEs were performed by consultants and 13.0% were performed by trainees. The laparoscopic-to-open conversion rate was 12.5%. The median operation time was 111 minutes (range: 75-155 minutes). Median hospital stay was 6 days (range: 4-11 days) for emergency LBDEs and 1 day (range: 1-4 days) for elective LBDEs. Overall morbidity was 21.5%. Bile leak rate was 5.3%. Thirty-day readmission and mortality rates were 12.1% and 0.4%, respectively.

Conclusions

The single-stage approach to managing BDS was underutilised. An additional prospective study with a longer study period is needed to verify this finding.

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.

Comparing One-Stage vs Two-Stage Approaches for the Management of Choledocholithiasis

BACKGROUND

The management of symptomatic choledocholithiasis remains a controversial issue. At present, the three most common management options for choledocholithiasis include a preoperative endoscopic retrograde cholangiopancreatography with sphincterotomy and stone extraction followed by laparoscopic cholecystectomy, then by either an intraoperative endoscopic retrograde cholangiopancreatography with sphincterotomy or a laparoscopic common bile duct exploration. The purpose of this study was to assess the consequences of the decision to pursue each of these three methods.

METHODS

We conducted a review of the existing data comparing these three management options. The literature from 2009 to 2021 pertaining to these three methods was reviewed for data on duct clearance, morbidity, mortality, recurrence rate, length of stay, and operative time. Next, we constructed decision trees for each method using a utility score analysis, and these utility scores were used to create a sensitivity analysis based on stone clearance rate.

RESULTS

Laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiopancreatography had a utility score of 0.9910, a stone clearance rate of 95.5%, a morbidity of 6.3%, and a mortality of 0.2%. Preoperative endoscopic retrograde cholangiopancreatography with laparoscopic cholecystectomy had a utility score of 0.9629, a stone clearance rate of 85.5%, a morbidity of 13.3%, and a mortality of 0.8%. Laparoscopic cholecystectomy with common bile duct exploration had a utility score of 0.9882, a stone clearance rate of 88.3%, a morbidity of 12.9%, and a mortality of 0.3%.

CONCLUSION

We have shown that a laparoscopic cholecystectomy with an intraoperative endoscopic retrograde cholangiopancreatography is associated with the best overall outcomes.

Laparo-endoscopic management of chole-choledocholithiasis: Rendezvous or intraoperative ERCP? A single tertiary care center experience

Introduction

The management of chole-choledocholithiasis remains a matter of debate to preserve minimal invasive management and different options have been proposed, with single- or two-stage approaches. Two techniques of single-stage approach are intraoperative ERCP and laparoscopic rendezvous, which have the great advantage of reducing the length of hospital stay with increased patient compliance. This retrospective study aims to evaluate and compare the efficacy and safety of intraoperative ERCP and rendezvous technique for more than 15 years.

Materials and methods

Clinical records of 113 patients who underwent single-stage management for chole-choledocholithiasis between January 2003 and December 2020 were retrospectively reviewed using a prospectively maintained database. Patients were separated into two groups: those managed with intraoperative ERCP and those with rendezvous, and their intraoperative and postoperative parameters were compared. All patients were followed up for 6 months in an outpatient setting.

Results

A total of 68 (60%) patients were treated with intraoperative ERCP, while the remaining 45 (40%) were treated with rendezvous. There were no significant differences in terms of comorbidities. ERCP was performed with a median operative time of 145 min (104–168) and an endoscopic time of 27 min (15–36). Meanwhile, rendezvous was performed with a significantly lower operative [120 min (94–147)] and endoscopic time [15 min (12–22)]. No intraoperative complications were recorded. Patients treated with rendezvous had a significantly shorter median hospitality stay [4 (3–5) vs. 3 (2–4) days, p < 0.05]. No hospital readmissions or mortalities were observed in either group after 30 days. Ten mild pancreatitis cases were observed, mainly in the intraoperative ERCP group (9 vs. 1, p < 0.05), and all were treated conservatively. Only two patients treated with intraoperative ERCP developed biliary complications later on.

Conclusion

Laparoscopic rendezvous should be considered a preferable alternative to intraoperative ERCP for the treatment of patients with concomitant CBD stones and gallstones.

The safety and feasibility of laparoscopic approach for the management of intrahepatic and extrahepatic bile duct stones in patients with prior biliary tract surgical interventions

The purpose of this study was to compare the efficacy and safety of laparoscopic and open reoperation for intrahepatic and extrahepatic bile duct stones patients with previous biliary tract surgical procedures. The clinical data were retrospectively analyzed of intrahepatic and extrahepatic bile duct stones patients with previous biliary tract surgical procedures who underwent reoperation in the Second General Surgery Department of China Medical University from January 2012 to February 2018. 44 eligible cases were selected. In accordance with the surgical procedures, they were divided into a laparoscopy group (n = 23) and an open surgery group (n = 21). No statistically significant differences were found in the preoperative general clinical data between the two group. Two patients in the laparoscopy group were converted to open surgery. Comparisons between the two groups showed that the intraoperative blood loss [90.87 ± 62.95 (ml) vs. 152.38 ± 118.82 (ml)], the proportion of postoperative analgesia [10/23 (43.5%) vs. 16/21 (76.2%)], and the length of stay [7.19 ± 5.32 (d) vs. 11.00 ± 4.66 (d)] in the laparoscopy group were significantly lower than those in the open surgery group (P < 0.05). Laparoscopic biliary reoperation for intrahepatic and extrahepatic bile duct stones was feasible. Compared with open surgery, laparoscopic surgery has the advantages of less bleeding, a shorter postoperative length of stay, and a lower rate of additional postoperative analgesia.

Effect of live Clostridium typhimurium tablets on nutritional status, Th1/Th2 cells, and prognosis of patients with diarrhea after laparoscopic surgery for gallbladder stones

BACKGROUND

Diarrhea after simple laparoscopic cholecystolithiasis is obvious, and the effect of traditional antidiarrheal drugs is limited. Clostridium butyricum viable tablets can prevent and treat diarrhea by correcting immune disorders and maintaining the balance of intestinal flora, but its application in patients with diarrhea after laparoscopic cholecystolithiasis lacks evidence-based support.

AIM

To investigate the effects of live Clostridium typhimurium tablets on the nutritional status, Th1/Th2 cells, and prognosis of patients with diarrhea after laparoscopic surgery for gallbladder stones.

METHODS

Prospectively, 200 patients with diarrhea after laparoscopic surgery for gallbladder stones at Linhai Hospital of Traditional Chinese Medicine from August 2017 to August 2021 were selected and divided into either a control group or an experimental group using the random number table method, with 100 cases in each group. Both groups received roperamide hydrochloride capsules, and the experimental group was additionally given Clostridium typhimurium live tablets. The treatments lasted 4 weeks in both groups. The prognosis and symptom scores, number of bowel movements, Th1/Th2 cells and their characteristic cytokines [interferon (INF-γ) and interleukin-4 (IL-4)], intestinal flora (Enterococcus, Bifidobacterium, and Escherichia coli), intestinal barrier function indexes [intestinal fatty acid binding protein (IFABP), diamine oxidase (DAO), and urinary lactose/mannitol (L/M)], and nutritional status [albumin (ALB), transferrin (TEN), and prealbumin (PA)] were compared between the two groups.

RESULTS

After 4 weeks of treatment, the scores of stool properties and abdominal discomfort in the experimental group were lower than those of the control group, and the number of bowel movements was less than that of the control group (P < 0.05); IFABP, DAO, L/M, INF-γ, and Th1/Th2 ratio in the experimental group were lower than those of the control group, and IL-4 was higher than that of the control group (P < 0.05); enterococci and Escherichia coli of the experimental group were lower than those of the control group, and Bifidobacterium was higher than that of the control group (P < 0.05). TFN, PA, and ALB after 4 weeks of treatment were higher in both groups than those before treatment (P < 0.05). When follow-up was performed at 12 weeks after treatment, there was no statistically significant difference between the two groups in terms of disease recurrence rate (P > 0.05).

CONCLUSION

Clostridium typhimurium tablets help to relieve clinical symptoms, reduce Th1/Th2 cell expression, and improve nutritional status in patients with diarrhea after laparoscopic surgery for gallbladder stones, and the mechanism may be related to the regulation of intestinal microecological balance.

Effectiveness of Laparoscopic Cholecystectomy in Patients with Gallbladder Stones with Chronic Cholecystitis

Objective

To assess the effectiveness of laparoscopic cholecystectomy in patients with gallbladder stones and chronic cholecystitis.

Methods

From July 2018 to January 2020, 90 patients with gallbladder stones and chronic cholecystitis assessed for eligibility were recruited and concurrently assigned (1 : 1) to receive either small-incision cholecystectomy (observation group) or laparoscopic cholecystectomy (experimental group). Outcome measures included operation time, intraoperative bleeding volume, postoperative hospital stay, c-reactive protein (CRP), interleukin (IL)-6, tumor necrosis factor-α (TNF-α), gastrin (GAS), vasoactive intestinal peptide (VIP), motilin (MOT), and adverse events.

Results

Patients given laparoscopic cholecystectomy showed lower levels of operation-related indices versus those receiving small-incision cholecystectomy (P < 0.05). Laparoscopic cholecystectomy resulted in lower postoperative levels of CRP, IL-6, and TNF-α in the patients versus small-incision cholecystectomy (P < 0.05). Patients receiving laparoscopic cholecystectomy showed better GAS, VIP, and MOT levels than those receiving small-incision cholecystectomy (P < 0.05). The eligible patients after laparoscopic cholecystectomy had a significantly lower incidence of adverse events versus those after small-incision cholecystectomy (P < 0.05).

Conclusion

Laparoscopic cholecystectomy effectively shortens the operative time and length of hospital stay in patients with gallbladder stones and chronic cholecystitis, reduces intraoperative bleeding, attenuates the inflammatory response, and enhances the gastrointestinal function, with less surgical trauma and high safety. Clinical trials are, however, required prior to promotion.

Controversias en cirugía: colelitiasis y coledocolitiasis ¿Exploración de vías biliares laparoscópica más colecistectomía laparoscópica (cirugía en un paso) o CPRE y colecistectomía laparoscópica (cirugía en dos pasos)?

Introducción. La colelitiasis tiene una prevalencia del 15 % y el 21 % tendrá coledocolitiasis al momento de la colecistectomía, con 50 % de probabilidad de presentar complicaciones asociadas. Desde el advenimiento de la colecistectomía laparoscópica, el abordaje de la coledocolitiasis ha sido endoscópico, usualmente en un tiempo diferente al vesicular, sin embargo, los avances en laparoscopia han permitido explorar la vía biliar común por la misma vía, pudiendo realizar ambos procedimientos en el mismo tiempo de forma segura. Métodos. Se realizó una búsqueda de la literatura existente con relación al enfoque para el manejo de la colecistocoledocolitasis en un paso comparado con dos pasos. Resultados. Existe evidencia que demuestra mayor efectividad del abordaje en dos pasos, con CPRE y posterior colecistectomía laparoscópica, sobre el abordaje en un paso, especialmente en la tasa de fuga biliar y de cálculos retenidos. El enfoque en un paso con exploración de vías biliares y colecistectomía laparoscópica en el mismo tiempo es seguro, con alta tasa de éxito, baja incidencia de complicaciones, menor estancia hospitalaria y costos. Conclusión. El abordaje laparoscópico en un solo paso es un procedimiento seguro y eficaz para el manejo de la colecisto-coledocolitiasis, con el beneficio de estancia hospitalaria menor, sin embargo, se requieren habilidades técnicas avanzadas en cirugía laparoscópica. En nuestro medio ya existe una infraestructura para el manejo híbrido con CPRE y colecistectomía laparoscópica, pudiéndose realizar ambos en el mismo tiempo, para reducir estancia y costos.

Predictors for stone recurrence after a successful common bile duct surgical exploration for choledocholithiasis

BACKGROUND

Recurrence after common bile duct stone (CBDS) clearance is the major long-term drawback of their management. Its prevalence is significant, and it occurs after all primary therapeutic alternatives. The aim of this study was to determine the predictive factors associated with stone recurrence after surgical common bile duct exploration (CBDE).

METHODS

A retrospective cohort study based on patients undergoing CBDE between 2000 and 2018 was conducted. Uni- and multivariate hierarchical regression analyses were performed to assess the independent predictive factors associated with recurrent CBDS in patients with initially successful surgery.

RESULTS

A total of 365 patients underwent successful surgical procedures. After a median follow-up of 43.2 (IQR 84) months, 31 (8.4%) patients were diagnosed with CBD stone recurrence. The median time to recurrence was 30.3 (IQR 38) months. The only variable associated with CBDS recurrence was preoperative endoscopic sphincterotomy (HR 2.436, 95% CI: 1.031-5.751, P = 0.042)).

CONCLUSION

Patients who undergo preoperative endoscopic sphincterotomy and then cholecystectomy with successful common bile duct clearance may be at increased risk for recurrent stone disease compared to those who go straight to surgery.

Surgical Treatment for Choledocholithiasis Following Repeated Failed Endoscopic Retrograde Cholangiopancreatography

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is the first line treatment for choledocholithiasis. In many occasions, several attempts of ERCP are performed until failure is declared and surgical treatment is applied, in many times following procedure-related complications. We present the results of surgical management of patients with choledocholithiasis following repeated failures of ERCP due to impaction of multiple large stones.

METHODS

Patients that underwent surgical treatment for choledocholithiasis following repeated ERCP attempts between January 2006 and December 2018 were retrospectively assessed. Post-ERCP complications were evaluated and the surgical approach, technique, and outcomes were assessed.

RESULTS

One hundred and two patients were operated on for choledocholithiasis following repeated failed ERCP. All the patients had at least 2 failed attempts (mean = 3.2 ± 1.7), and 25 (23.5%) suffered major ERCP-related complications. Following choledochotomy and stone extraction, bilioenteric anastomosis was done in the vast majority of patients (90.2%), most commonly choledochoduodenostomy (62%). Thirty-eight (37%) patients had minimally invasive procedure (laparoscopic n = 26, robotic assisted n = 12). Major post-operative complications (Clavien-Dindo ≥ 3) occurred in 24 patients (23.5%). Nine patients (8.8%) were re-operated and 10 (9.8%) were readmitted within 30 days from surgery. Three patients died within 30 days from surgery. Older patients had significantly more ERCP attempts and suffered higher post-operative mortality. During a median follow-up of 70 months, the only biliary complication was an anastomotic stricture in one patient.

CONCLUSION

Surgery for CBDS after failure of ERCP is safe and provides a highly effective long-term solution.

Greater than or equal to 8 mm is a safe diameter of common bile duct for primary duct closure: single-arm meta-analysis and systematic review

Greater than or equal to 8 mm was often used as the safe diameter of primary duct closure (PDC) after laparoscopic common bile duct exploration (LCBDE) in previous studies, but it is impossible to verify the source of this safe diameter, and lack of evidence for the safe diameter of PDC. Hence, this study evaluates the incidence of postoperative complications by single-arm meta-analysis to demonstrate the feasibility of using 8 mm as the safe diameter of PDC, so as to provide reference for clinical selection. Eligible studies were searched by MEDLINE, the Cochrane Library, Embase, and Web of Science from January 1995 to May 2021, investigating eligible literature using PDC after LCBDE for methods of common bile duct closure. The single-arm meta-analysis was analyzed by "meta" package under R 4.0.5, and the pooled incidence of postoperative complications was calculated. Twelve literatures were enrolled in this single-arm meta-analysis including 792 patients. The pooled complications rate including total complications (13.1%, 95% CI 10.1-15.6%), total biliary duct-related complications (9.4%, 95% CI 7.4-11.6%), residual stones (1.3%, 95% CI 0.3-2.7%), bile leakage (5.1%, 95% CI 3.5-6.9%), postoperative pneumonia (2.1%, 95% CI 0.8-3.8%), postoperative acute pancreatitis (1.8%, 95% CI 0.2-4.3%), and stone recurrence (2.6%, 95% CI 1.1-4.4%). The clinical indication of PDC after LCBDE should follow that the diameter of common bile duct ≥ 8 mm as the safe diameter.

Is Laparoscopic Common Bile Duct Exploration Safe For The Oldest old patients?

Background

This study aimed to identify the risk factors for postoperative complications of laparoscopic common bile duct exploration (LCBDE) in the oldest old patients aged 80 years or older.

Methods

From March 2001 to October 2020, 363 patients underwent LCBDE with stone removal. Based on their ages, they were divided into two groups, those younger than 80 years (n=240) and those 80 years old or older (n=123). We compared patient demographics, disease characteristics, surgical outcomes, and postoperative complications based on these groups.

Results

The older group had a higher proportion of patients with a Charlson Comorbidity Index ≥5 (p<0.001) and the American Society of Anesthesiologist (ASA) physical status classification ≥3 (p<0.001). In addition, the older group had longer postoperative hospital stays than younger group (7.5±6.1 days vs. 6.2±3.9 days, p=0.013). However, there were no significant differences between groups according to the postoperative complications (13.8% vs. 20.3%, p=0.130). According to multivariate analysis, the risk factors for postoperative complications were Charlson Comorbidity Index ≥5 (odds ratio [OR]=2.307; 95% confidence interval [CI], 1.162–4.579; p=0.017) and operative time >2 hours (OR=3.204; 95% CI, 1.802–5.695; p<0.001).

Conclusion

In patients with Charlson Comorbidity Index <5 and operation time <2 hours, LCDBE with stone removal can be considered safe for the oldest old patients.

Comparison of Laparoscopic Common Bile Duct Exploration with Endoscopic Retrograde Cholangiopancreatography for Common Bile Duct Stones After Cholecystectomy

Background: Few studies have focused on the treatment of common bile duct (CBD) stones after cholecystectomy, for which optimal treatment options remain unclear. Aims: To compare the safety and efficacy of laparoscopic common bile duct exploration (LCBDE) versus endoscopic retrograde cholangiopancreatography (ERCP) for CBD stone treatment after cholecystectomy. Materials and Methods: A total of 201 patients were enrolled in this retrospective cohort study, of whom 134 with ≤3 stones and a maximum stone diameter of <15 mm were classified as subgroup 1, and 67 with >3 stones or a maximum stone diameter of ≥15 mm were classified as subgroup 2. Perioperative characteristics were also analyzed. Results: ERCP subgroup 1 exhibited a shorter operative time (P < .001), postoperative hospital stay (P < .001), and lower incidence of bile leakage (P = .034) than LCBDE subgroup 1. ERCP subgroup 2 exhibited a shorter operative time (P < .001) and shorter postoperative hospital stay (P < .001) than LCBDE subgroup 2. However, LCBDE subgroup 2 exhibited a greater rate of complete stone removal (P = .044) and a lower incidence of acute pancreatitis (P = .037) than ERCP subgroup 2. Conclusions: For treatment of CBD stones after cholecystectomy, ERCP was superior in cases involving ≤3 stones and a maximum stone diameter of <15 mm. Among those with >3 stones or maximum stone diameter of ≥15 mm, LCBDE demonstrated certain advantages.

Destiny for Rendezvous: Is Cholecysto/Choledocholithiasis Better Treated with Dual- or Single-Step Procedures?

Biliary lithiasis is common worldwide, affecting almost 20% of the general population, though few experience symptoms. The frequency of choledocholithiasis in patients with symptomatic cholelithiasis is estimated to be 10-33%, depending on patients' age. Unlike gallbladder lithiasis, the medical and surgical treatment of common bile duct stones is uncertain, having changed over the last few years. The prior gold standard treatment for cholelithiasis and choledocholithiasis was open cholecystectomy with bile duct clearance, choledochotomy, and/or surgical sphincterotomy. In the last 10-15 years, new treatment approaches to the complex pathology of choledocholithiasis have emerged with the advent of endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic surgery, and advanced diagnostic procedures. Although ERCP followed by laparoscopic cholecystectomy is the preferred mode of management, a single-step strategy (laparo-endoscopic rendezvous) has gained acceptance due to lesser morbidity and a lower risk of iatrogenic damage. Given the above, a tailored approach relying on careful evaluation of the disease is necessary in order to minimize complication risks and overall costs. Yet, the debate remains open, with no consensus on the superiority of laparo-endoscopic rendezvous to more conventional approaches.

Inpatient Choledocholithiasis Management: a Cost-Effectiveness Analysis of Management Algorithms

BACKGROUND

Choledocholithiasis is commonly encountered. It is frequently managed with laparoscopic common bile duct exploration or endoscopic retrograde cholangiopancreatography (either preoperative, intraoperative, or postoperative relative to laparoscopic cholecystectomy). The purpose of this study is to determine the most cost-effective method to manage inpatient choledocholithiasis.

METHODS

A decision tree model was created to evaluate the cost-effectiveness of laparoscopic common bile duct exploration and preoperative, intraoperative, and postoperative endoscopic retrograde cholangiopancreatography. The primary outcome was incremental cost-effectiveness ratio with a ceiling willingness to pay threshold assumed of $100,000 per quality-adjusted life year. Model parameters were determined through review of published literature and institutional data. Costs were from the perspective of the healthcare system with a time horizon of 1 year. Sensitivity analyses were performed on model parameters.

RESULTS

In the base case analysis, laparoscopic common bile duct exploration was cost-effective, resulting in 0.9909 quality-adjusted life years at an expected cost of $18,357. Intraoperative endoscopic retrograde cholangiopancreatography yielded more quality-adjusted life years (0.9912) at a higher cost ($19,717) with an incremental cost-effectiveness ratio of $4,789,025, exceeding the willingness to pay threshold. Both preoperative and postoperative endoscopic retrograde cholangiopancreatographies were eliminated for being both more costly and less effective. Laparoscopic common bile duct exploration remained cost-effective if the probability of successful biliary clearance was above 0.79, holding all other variables constant. If its base cost remained below $18,400 and intraoperative endoscopic retrograde cholangiopancreatography base cost rose above $18,200, then laparoscopic common bile duct exploration remained cost-effective.

CONCLUSION

Laparoscopic common bile duct exploration is the most cost-effective method to manage choledocholithiasis. Efforts to ensure availability of local expertise and resources for this procedure are warranted.