Advantages of laparoscopic common bile duct exploration in common bile duct stones

Application of laparoscopic backtracking full-thickness continuous everting suture for non-AOSC choledocholithiasis

BACKGROUND

Based on the current trend of increasing incidence of choledocholithiasis, it is of great significance to explore the closure method of the common bile duct during laparoscopic choledocholithotomy.

METHODS

Backtracking full-thickness continuous everting suture was selected for primary closure of the common bile duct suture, while traditional T-tube drainage was selected for the control group. Propensity score matching (PSM) was used to reduce baseline differences between the two groups.

RESULT

The intraoperative blood loss, operation time, postoperative recovery speed, postoperative bleeding, postoperative pancreatitis, recurrence rate of bile duct stones, and hospitalization time in the primary closure group were all less than those in the T-tube drainage group.

CONCLUSION

Under certain conditions, backtracking full-thickness continuous everting suture could benefit patients with choledocholithiasis compared with traditional T-tube drainage.

Comparative analysis of laparoscopic choledocholithiasis and ERCP treatment after cholecystectomy

OBJECTIVE

To compare the overall efficacy of laparoscopic common bile duct exploration(LCBDE) with endoscopic retrograde cholangiopancreatography (ERCP ) after cholecystectomy.

METHODS

From January 2017 to July 2021, Seventy patients with Choledocholithiasis after cholecystectomy who were admitted to our hospital were selected and divided into ERCP and LCBDE groups. comparison of baseline characteristics, clinical efficacy and postoperative complications between the ERCP and LCBDE.

RESULTS

①The overall efficacy rate of LCBDE was 97.1%, while the overall efficacy rate in the ERCP group was 76.6%. The LCBDE group demonstrated a significantly higher overall effective rate compared to the ERCP group, with a statistically significant difference (p < 0.05). ②The preoperative and postoperative complications of the LCBDE group were visibly lower than the other group (P < 0.05). The postoperative time to oral intake, postoperative ventilation time, length of hospital stay, and hospital costs were higher in the ERCP group compared to the LCBDE group, with a statistically significant difference (P < 0.05).

CONCLUSION

In the treatment of common bile duct stones after cholecystectomy, LCBDE is a superior choice compared to ERCP in terms of stone diameter, quantity, clearance rate, and hospital costs.

One-step laparoscopic cholecystectomy with common bile duct exploration and stone extraction versus two-step endoscopic retrograde cholangiography with stone extraction plus laparoscopic cholecystectomy for patients with common bile duct stones: a randomised feasibility and pilot clinical trial-the preGallStep trial

BACKGROUND

Endoscopic retrograde cholangiography (ERC) with stone extraction and papillotomy with subsequent laparoscopic cholecystectomy-the two-step approach-is the standard treatment of common bile duct stones in many countries. However, ERC is associated with a high risk of complications and more than half of patients require multiple ERCs. Meta-analyses of randomised clinical trials find no major differences of the two-step approach in comparison with laparoscopic cholecystectomy with intraoperative laparoscopic stone clearance-the one-step approach. Currently, there are insufficient data to ascertain superiority.

METHODS

The preGallstep trial is an investigator-initiated, multicentre randomised feasibility and pilot clinical trial with blinded outcome assessment. Eligible patients are patients with common bile duct stones (identified by magnetic resonance cholagiopancreatography), age 18 years or above with the possibility to perform both interventions within a reasonable time. We intent to randomise 150 participants allocated 1:1. The experimental intervention is the one-step approach. This consists of laparoscopic common bile duct exploration plus laparoscopic cholecystectomy. The control intervention is the two-step approach which consists of ERC plus sphincterotomy (first step) and subsequent laparoscopic cholecystectomy (second step). Feasibility outcomes include the proportion of eligible patients not wanting to participate, reasons for rejection to participate, difficulties during the informed consent procedure, difficulties with randomisation, difficulties with data management, difficulties with blinding patient charts and forms and difficulties with maintaining blinding for the outcome assessors. The primary pilot outcome is the proportion of participants with at least one postoperative complication according to the Clavien-Dindo score grade II and above until 90 days after randomisation. This outcome will be used for a future sample size calculation of a larger pragmatic trial. Further, a range of clinical explorative outcomes will be assessed.

DISCUSSION

As no sample size is estimated in this trial, there is a risk of wrongly assessing the effect on the patient-related outcome. The surgical procedures cannot be blinded. However, blinding will be employed in all other aspects of the trial, including the establishment of a blinded outcome adjudication committee with three independent assessors. Heterogeneity in screening, randomisation, diagnostics, treatment procedures, interventions and follow-up across trial sites may cause challenges in conducting a larger pragmatic trial. To monitor inter-site differences, we have implemented a central data monitoring scheme.

TRIAL REGISTRATION

ClinicalTrials.gov identification: NCT04801238 , Registered on 16 March 2021.

EAES rapid guideline: updated systematic review, network meta-analysis, CINeMA and GRADE assessment, and evidence-informed European recommendations on the management of common bile duct stones

BACKGROUND

Choledocholithiasis presents in a considerable proportion of patients with gallbladder disease. There are several management options, including preoperative or intraoperative endoscopic cholangiopancreatography (ERCP), and laparoscopic common bile duct exploration (LCBDE).

OBJECTIVE

To develop evidence-informed, interdisciplinary, European recommendations on the management of common bile duct stones in the context of intact gallbladder with a clinical decision to intervene to both the gallbladder and the common bile duct stones.

METHODS

We updated a systematic review and network meta-analysis of LCBDE, preoperative, intraoperative, and postoperative ERCP. We formed evidence summaries using the GRADE and the CINeMA methodology, and a panel of general surgeons, gastroenterologists, and a patient representative contributed to the development of a GRADE evidence-to-decision framework to select among multiple interventions.

RESULTS

The panel reached unanimous consensus on the first Delphi round. We suggest LCBDE over preoperative, intraoperative, or postoperative ERCP, when surgical experience and expertise are available; intraoperative ERCP over LCBDE, preoperative or postoperative ERCP, when this is logistically feasible in a given healthcare setting; and preoperative ERCP over LCBDE or postoperative ERCP, when intraoperative ERCP is not feasible and there is insufficient experience or expertise with LCBDE (weak recommendation). The evidence summaries and decision aids are available on the platform MAGICapp ( https://app.magicapp.org/#/guideline/nJ5zyL ).

CONCLUSION

We developed a rapid guideline on the management of common bile duct stones in line with latest methodological standards. It can be used by healthcare professionals and other stakeholders to inform clinical and policy decisions.

GUIDELINE REGISTRATION NUMBER

IPGRP-2022CN170.

National clinical practice guidelines for the treatment of symptomatic gallstone disease: 2021 recommendations from the Danish Surgical Society

BACKGROUND AND OBJECTIVE

Gallstones are highly prevalent, and more than 9000 cholecystectomies are performed annually in Denmark. The aim of this guideline was to improve the clinical course of patients with gallstone disease including a subgroup of high-risk patients. Outcomes included reduction of complications, readmissions, and need for additional interventions in patients with uncomplicated gallstone disease, acute cholecystitis, and common bile duct stones (CBDS).

METHODS

An interdisciplinary group of clinicians developed the guideline according to the GRADE methodology. Randomized controlled trials (RCTs) were primarily included. Non-RCTs were included if RCTs could not answer the clinical questions. Recommendations were strong or weak depending on effect estimates, quality of evidence, and patient preferences.

RESULTS

For patients with acute cholecystitis, acute laparoscopic cholecystectomy is recommended (16 RCTs, strong recommendation). Gallbladder drainage may be used as an interval procedure before a delayed laparoscopic cholecystectomy in patients with temporary contraindications to surgery and severe acute cholecystitis (1 RCT and 1 non-RCT, weak recommendation). High-risk patients are suggested to undergo acute laparoscopic cholecystectomy instead of drainage (1 RCT and 1 non-RCT, weak recommendation). For patients with CBDS, a one-step procedure with simultaneous laparoscopic cholecystectomy and CBDS removal by laparoscopy or endoscopy is recommended (22 RCTs, strong recommendation). In high-risk patients with CBDS, laparoscopic cholecystectomy is suggested to be included in the treatment (6 RCTs, weak recommendation). For diagnosis of CBDS, the use of magnetic resonance imaging or endoscopic ultrasound prior to surgical treatment is recommended (8 RCTs, strong recommendation). For patients with uncomplicated symptomatic gallstone disease, observation is suggested as an alternative to laparoscopic cholecystectomy (2 RCTs, weak recommendation).

CONCLUSIONS

Seven recommendations, four weak and three strong, for treating patients with symptomatic gallstone disease were developed. Studies for treatment of high-risk patients are few and more are needed.

ENDORSEMENT

The Danish Surgical Society.

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.

Advances in Risk Factors for Recurrence of Common Bile Duct Stones

Choledocholithiasis is a chronic common disease. The incidence of cholelithiasis is 5%-15%, of which 5%-30% are combined with Choledocholithiasis. Although endoscopic cholangiopancreatography (ERCP) + endoscopic sphincterotomy (EST) is the most common treatment procedure, which clearance rate is up to 95%, the incidence of recurrent choledocholithiasis was 4%-25%. The risk factors of recurrence after choledocholithiasis clearance are the focuses of current researches, which are caused by multiple factors. We first systematically summarize the risk factors of common bile duct stones (CBDS) recurrence into five aspects: first-episode stone related factors, congenital factors, biological factors, behavioral intervention factors, and the numbers of stone recurrence.

The Efficiency of Laparoscopic Common Bile Duct Exploration in Endoscopic Retrograde-Cholangiopancreatography-Limited Setting in a Peripheral University Hospital

Background: The aim of this study is to evaluate complications and costs in patients treated with laparoscopic and open method for common bile duct (CBD) stones. Secondary aim is to compare the effectiveness, safety, and outcomes of these methods. In addition, it is aimed to review the feasibility of laparoscopic method in rural areas. Methods: Seventy-one patients were analyzed retrospectively. Patients were divided into two groups as open and laparoscopic surgical method. These groups were analyzed comparatively in terms of complications and costs. Subgroups were formed from patients who underwent T-tube drainage, primary closure, and biliary anastomosis as choledochotomy management. As a secondary outcome, these three subgroups were investigated in terms of complications and cost. Results: The cost was lower in open method compared to laparoscopic method (484$, 707$, P = .002). There was no significant difference in postoperative complications between groups (P = .257). While the mean hospital stay was longer in the open group, the operation time was shorter (P = .002, P = .03). The mean length of hospital stay in the T-tube group was significantly higher than the primary closure (P = .001). The cost in the T-tube group was significantly higher than the primary closure and biliary anastomosis groups. Conclusion: Laparoscopic CBD exploration by experienced surgeons in endoscopic retrograde-cholangiopancreatography-limited settings is an effective and safe method in the treatment of choledocholithiasis. This procedure should not be limited to reference centers and should be performed safely in rural areas by well-trained surgeons.

Laparoscopic Common Bile Duct Exploration With Primary Closure After Failed Endoscopic Retrograde Cholangiopancreatography Without Intraoperative Cholangiography: A Case Series from a Referral Center in Bogota, Colombia

Background: Despite the effectiveness of laparoscopic common bile duct (CBD) surgery, no case series details the use and advantages of laparoscopic CBD exploration (LCBDE) without use of intraoperative cholangiography (IOC) in endoscopic retrograde cholangiopancreatography (ERCP) failure. Therefore, we present a case series regarding our success with LCBDE in managing CBD stones (CBDSs) using laparoscopic technique without IOC. Materials and Methods: We performed a descriptive retrospective observational study. Patients with CBDSs, alone or along with gallbladder stones, were treated through LCBDE with primary CBD closure after failed ERCP. Results: All patients underwent LCBDE with choledocotomy and primary duct closure. Patients with gallbladder stones underwent laparoscopic cholecystectomy (78%). All procedures were successful, and no conversions occurred. Surgery duration averaged 106 minutes. Intraoperative bleeding averaged 15 cc, and no mortalities occurred. No patients required additional surgery or intensive care unit admission. Hospitalization duration averaged 5 days. Conclusions: Therefore, a laparoscopic approach with primary CBD closure after failed ERCP for complex CBDSs is safe and effective.

Single-stage treatment with ERCP and laparoscopic cholecystectomy versus two-stage treatment with ERCP followed by laparoscopic cholecystectomy within six to eight weeks: a retrospective study

Objectives

Obstructive jaundice is one of the earliest symptoms of a hepatobiliary system disorder. The aim of the present study was to compare single stage endoscopic retrograde cholangiopancreatography (ERCP)/laparoscopic cholecystectomy (LC) and two-stage ERCP and LC with respect to the frequency of imaging, duration of anesthesia and the length of stay in our clinic.

Material and Methods

Of the 350 patients undergoing ERCP between 01.01.2015 and 31.12.2016, 31 patients with single-stage ERCP and LC were assigned to Group A and 25 patients with two-stage ERCP followed by LC within 6-8 weeks were assigned to Group B. Eligibility criteria included ERCP duration, difficulty of the procedure, bile duct stones as demonstrated by imaging methods, no contraindications for LC and no suspected or known malignancy. The same surgeon performed ERCP and LC in both groups.

Results

No cases of morbidity or mortality occurred in any groups. The average length of stay was 8.03 ± 4.97 days in Group A, which was significantly longer (9.92 ± 4.05 days) in Group B (p <0.026). However, the length of stay (in days) was calculated as the time from presentation to hospital until discharge and not the time elapsed after the procedure. Imaging methods were used 3.9 ± 3.07 times in Group A and significantly more frequently (5.92 ± 2.55 times) in Group B (p <0.001). Total duration of anesthesia was not statistically significantly different between the study groups (154.06 ± 53.76 min in Group A and 167.04 ± 75.17 min in Group B).

Conclusion

In conclusion, single-stage ERCP/LC is associated with shorter hospital stay and lower frequency of imaging and can be safely used in selected cases. No cases of pancreatitis or mortality occurred following the single-stage procedure. The single-stage procedure can be safely used in selected patients with obstructive jaundice.