Laparoscopic common bile duct exploration and primary closure of choledochotomy after failed endoscopic sphincterotomy

Surgical strategies for challenging common bile duct stones in the endoscopic era: A comprehensive review of current evidence

While endoscopic retrograde cholangiopancreatography (ERCP) remains the primary treatment modality for common bile duct stones (CBDS) or choledocholithiasis due to advancements in instruments, surgical intervention, known as common bile duct exploration (CBDE), is still necessary in cases of difficult CBDS, failed endoscopic treatment, or altered anatomy. Recent evidence also supports CBDE in patients requesting single-step cholecystectomy and bile duct stone removal with comparable outcomes. This review elucidates relevant clinical anatomy, selection indications, and outcomes to enhance surgical understanding. The selection between trans-cystic (TC) vs trans-choledochal (TD) approaches is described, along with stone removal techniques and ductal closure. Detailed surgical techniques and strategies for both the TC and TD approaches, including instrument selection, is also provided. Additionally, this review comprehensively addresses operation-specific complications such as bile leakage, stricture, and entrapment, and focuses on preventive measures and treatment strategies. This review aims to optimize the management of CBDS through laparoscopic CBDE, with the goal of improving patient outcomes and minimizing risks.

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

Backgrounds/Aims

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

Methods

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

Results

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

Conclusions

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

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.

Long-Term Outcomes of Laparoscopic Common Bile Duct Exploration Through Diathermy, Choledochotomy, and Primary Closure: A 6-Year Retrospective Cohort Study

Background and Objective: Choledocholithiasis is a frequent pathology, unfortunately when its endoscopic management fails, there is no consensus of how it should be addressed. The aim of this study was to evaluate the safety, feasibility, and long-term outcomes of laparoscopic common bile duct exploration (LCBDE) using electrosurgery (coagulation) for choledochotomy followed by primary closure after endoscopic treatment failure. Materials and Methods: A retrospective cohort study of patients who underwent LCBDE from 2013 to 2018 was conducted in Bogotá, Colombia. Clinical demographics, operative outcomes, recurrence rate of common bile duct stones, and long-term bile duct complications were analyzed. A descriptive analysis was performed. Results: A total of 168 patients were analyzed. Most of the patients were males (53.37%) with a median age of 73 years with no comorbidities (65%). Stone clearance was successful in 167 patients (99.4%). Nonlethal complications were noted in 3 patients during the surgery or in the immediate postoperative (1.79%) and managed with T-tube or endoscopically. No cases of mortality surgery related were observed. There were no signs of any type of biliary injury or stricture observed in any of the patients during the 24-month follow-up period. Conclusions: LCBDE with diathermy and primary closure is a safe and effective treatment option for choledocholithiasis for failed endoscopic retrograde cholangiopancreatography in terms of long-term outcome as well as short-term outcome.

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.

Is the use of fully covered metal stents effective in the treatment of difficult lithiasis of the common bile duct?

BACKGROUND

The management of difficult lithiasis of common bile duct (CBD) often requires a multimodal approach. Fully Covered Metal Stents (FCSEMS) could fragment the stones, dilate strictures of the CBD and progressively enlarge the papillary orifice. The aim of the study was to evaluate the efficacy of FCSEMS in the treatment of difficult lithiasis of CBD.

METHODS

All consecutive cases of difficult lithiasis of CBD after an attempt of clearance with complete sphincterotomy were retrospectively considered from 2009 to 2019. Intrahepatic lithiasis cases were excluded. Multivariable analysis (stepwise logistic regression if p value < 0.1 at univariable analysis) was made to understand factors associated with efficacy of FCSEMS in difficult lithiasis of CBD.

RESULTS

163 cases of difficult lithiasis over 1516 cases of lithiasis of CBD (incidence of 11%) were considered. Among eligible patients, 96 (mean age 78 ± 11.9 years, 43% males) placed a FCSEMS during the first ERCP. Mean diameter of stone was 17.5 ± 5.5 mm. An attempt of dilation during the same procedure was made in 18% cases. After removal of the stent, 52 (54%) patients had complete clearance of CBD at cholangiography. The rest of patients (44), subsequently underwent multimodal treatment (final success of 95%). After logistic regression, variables positively associated with clearance of CBD were sex male (OR 3.5) and stent permanence ≥ 30 days (OR 3.2). Diameter of the stone ≥ 2 cm was associated with failure (OR 0.2). 7 post-ERCP pancreatitis, 6 post-sphincterotomy bleeding and 3 cholangitis occurred.

CONCLUSIONS

FCSEMS are useful in the approach of difficult lithiasis of CBD with no significant adverse events associated.

Systematic Review and Meta-analysis of Laparoscopic Common Bile Duct Exploration in Patients With Previous Failed Endoscopic Retrograde Cholangiopancreatography

BACKGROUND

The aim was to compare the outcomes of laparoscopic common bile duct exploration (LCBDE) after failed endoscopic retrograde cholangiopancreatography (group A) versus primary LCBDE (group B) for the management of gallbladder and common bile duct stones.

MATERIALS AND METHODS

A comprehensive and systematic literature search was performed in several databases, including PubMed, Ovid, and Cochrane Library. Meta-analysis of operative outcomes, postoperative outcomes, and gallstone clearance rates was conducted using random-effect models.

RESULTS

Six studies including 642 patients (239 in group A and 403 in group B) were included. The operative time was longer in group A (P=0.02). The overall complication, bile leakage, conversion, postoperative hospital stay, and reoperation were comparable in group A and group B. Similarly, no significant difference was present concerning the incidence of stone clearance, residual stone, and recurrent stone (P>0.05).

CONCLUSION

LCBDE is an alternative acceptable procedure when removal of common bile duct stones by endoscopic therapy fails.

Biliary tract exploration via left hepatic duct stump versus the common bile duct incision in left-sided hepatolithiasis: a meta-analysis

BACKGROUND

Left lateral hepatic resection is the preferred surgical approach for treating left hepatolithiasis. However, it is not clear whether cholangioscopy via left hepatic duct (LHD) orifice can replace conventional common bile duct (CBD) approach during laparoscopic procedures.

METHODS

We performed a comprehensive literature search by screening medical databases, then compared perioperative outcomes and occurrence of recurrent stones between LHD and CBD approaches.

RESULTS

A total of five studies, comprising 345 patients, were included in this meta-analysis. The reported operative times, intra-operative blood loss and incidence of post-operative complications were comparable between the approaches. Pooled results revealed a positive correlation between LHD approach with shorter length of hospital stay (standard mean difference = -1.36; 95% confidence interval: -2.10, -0.61; P < 0.001). Additionally, bile duct exploration via LHD orifice was associated with similar rate of recurrent stones and cholangitis across both groups.

CONCLUSIONS

Our results demonstrated that biliary tract exploration via LHD stump can be safely performed in left-sided hepatolithiasis. Additionally, the LHD approach was associated with comparable intra-operative outcomes and shorter post-operative hospitalization relative to CBD approach, and does not increase incidence of stone recurrence.

3D laparoscopic common bile duct exploration versus 2D in choledocholithiasis patients: a propensity score analysis

BACKGROUND

This study was designed to investigate whether 3D laparoscopic common bile duct (LCBDE) could improve surgical outcomes in choledocholithiasis patients compared with 2D LCBDE.

METHOD

Propensity score-matched analysis was performed to balance the bias in baseline characteristic between two groups.

RESULTS

213 patients underwent 3D LCBDE and 212 patients receiving 2D LCBDE were enrolled in this study. The operation time and blood loss in 3D group were significantly less than that in 2D group. After propensity score matching, a total of 114 paired cases were selected from the two groups. The operation time and blood loss in 3D group remain significantly lower than in 2D group. In the end, the subgroup analysis based on abdominal adhesion level was performed and it was observed that for patients with adhesion level 1 and level 2, 3D surgery could obviously decrease the operation time and intraoperative blood loss.

CONCLUSIONS

3D LCBDE would significantly reduce operation time, blood loss, and conversion rate to laparotomy in choledocholithiasis patients versus 2D LCBDE. For patients with abdominal adhesions level 1 and level 2, 3D LCBDE could provide better surgical outcomes than 2D LCBDE.

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.

Laparoscopic common bile duct exploration for elderly patients with choledocholithiasis: a systematic review and meta-analysis

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) has been becoming more and more popular in patients with symptomatic choledocholithiasis. However, the safety and effectiveness of LCBDE in elderly patients with choledocholithiasis is still uncertain. This meta-analysis is aimed to appraise the safety and feasibility of LCBDE for elderly patients with choledocholithiasis.

MATERIALS AND METHODS

Studies comparing elderly patients and younger patients who underwent LCBDE for common bile duct stone were reviewed and collected from the PubMed, Medline, EMBASE, and Cochrane Library. Primary outcomes were stone clearance rate, overall complication rate, and mortality rate. Secondary outcomes were operative time, conversion rate, pulmonary complication, bile leakage, reoperation, residual stone rate, and recurrent stone rate.

RESULTS

Nine studies, including two prospective studies and seven retrospective studies, met the inclusion criteria. There were 2004 patients in this meta-analysis, including 693 elderly patients and 1311 younger patients. There was no statistically significant difference between elderly patients and younger patients regarding stone clearance rate (OR 0.73; 95% CI 0.42-1.26; p = 0.25), overall complication rate (OR 1.31; 95% CI 0.94-1.82; p = 0.12), and mortality rate (OR 2.80; 95% CI 0.82-9.53; p = 0.10). Similarly, the operative time, conversion rate, bile leakage, reoperation, residual stone rate, and recurrent stone rate showed no significant difference between two groups (p > 0.05). While elderly patients showed high risk for pulmonary complication (OR 4.41; 95% CI 1.78-10.93; p = 0.001) compared with younger patients.

CONCLUSION

Although there is associated with higher pulmonary complication, LCBDE is still considered as a safe and effective treatment for elderly patients with choledocholithiasis.

T-tube-free single-incision laparoscopic common bile duct exploration plus cholecystectomy: a single centre experience

BACKGROUND

The present study aimed to explore the indications and feasibility of T-tube-free trans-umbilical single-incision laparoscopic common bile duct exploration (SILCBDE) plus laparoscopic cholecystectomy (LC) for treating choledocholithiasis.

METHODS

Patients hospitalized in the Second Affiliated Hospital (Shengjing Hospital) of China Medical University from January 2010 to January 2017 with the diagnosis of common bile duct stones and treated with T-tube-free trans-umbilical single-incision LC plus common bile duct exploration were retrospectively analysed.

RESULTS

A total of 37 male/female choledocholithiasis patients (mean age 65 years, range 29-86) were treated with T-tube-free trans-umbilical SILCBDE plus LC. No intraoperative complication or conversion to open surgery occurred in any of the cases. The mean operative time was 99.8 min (range 84-125) for endoscopic nasobiliary drainage group (n = 6), 113.8 min (range 70-150) for endoscopic retrogradebiliary drainage group (n = 2), 131.1 min (range 75-161) for pigtail J-tube group (n = 24), 113.7 min (range 100-150) for primary closure group (n = 5). The mean post-operative hospital stay length was 5.5 days (range 4-7) for endoscopic nasobiliary drainage group, 12.5 days (range 10-15) for endoscopic retrogradebiliary drainage group, 6.5 days (range 4-10) for J-tube group, 5.8 days (range 4-9) for primary closure group. Pancreatitis, bile leakage and peritonitis were not presented in any of the group. After 17-101 months follow-up, three patients presented recurrent common bile duct stones.

CONCLUSION

In selected cases, T-tube-free trans-umbilical SILCBDE plus LC is feasible and safe for experienced surgeons, and can achieve similar therapeutic effects as common LC plus common bile duct exploration procedures.

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

Objectives

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

Methods

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

Results

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

Conclusion

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

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

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

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

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

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

Objectives

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

Methods

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

Results

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

Conclusion

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Laparoscopic Common Bile Duct Exploration Is a Safe and Effective Strategy for Elderly Patients

PURPOSE

Laparoscopic common bile duct exploration (LCBDE) has been widely used to remove common bile duct (CBD) stones. However, surgery is not considered as the first treatment choice for elderly patients with CBD stones because of the potential risk of postoperative complications. This study aims to evaluate the safety and efficiency of LCBDE for elderly patients.

METHODS

From April 2011 to October 2016, 265 consecutive patients underwent LCBDE. We performed a retrospective study and divided these patients into 2 groups. The younger group was younger than 70 years old (n = 179), and the elderly group was 70 years old or older (n = 86). We compared patient demographics, clinical characteristics, intraoperative parameters, postoperative complications, and incidence of recurrent stone between the 2 groups.

RESULTS

The elderly patients had higher preoperative morbidity of chronic diseases, such as pulmonary diseases, heart diseases, arterial hypertension, and abdominal operation history ( P < .05). There were no significant differences between the 2 groups in terms of operation time, intraoperative blood loss, conversion rate to open surgery, total cost, overall complications, and incidence of recurrent stone ( P > .05).

CONCLUSION

LCBDE can also be carried out as a safe and effective approach to remove CBD stones in elderly patients, although they have higher risk of chronic diseases.

Laparoscopic common bile duct exploration in patients with previous upper abdominal surgery

BACKGROUND

Although patients with previous upper abdominal surgery are no longer considered as a contraindication in laparoscopic surgery, laparoscopic common bile duct exploration (LCBDE) for these patients is still controversial. The aim of this study was to evaluate the safety and effectiveness of LCBDE for patients with previous upper abdominal surgery.

METHODS

Two hundred and seventeen patients with common bile duct stones who underwent LCBDE in our institution from January 2010 to September 2017 were enrolled in the retrospective study. They were divided into two groups: group A, with previous upper abdominal surgery (n = 50) and group B, without previous upper abdominal surgery (n = 167). Patients' demographic, intraoperative, and postoperative outcomes were retrospectively analyzed.

RESULTS

Group A exhibited a longer operative time compared to group B (179.7 ± 61.5 vs. 156.0 ± 46.8 min, p = 0.014). There was no significant difference in intraoperative blood loss (123.9 ± 99.5 vs. 99.5 ± 84.7 mL, p = 0.087), postoperative hospital stay (7.4 ± 2.6 vs. 6.8 ± 2.3 d, p = 0.193), and overall complication rate (8.0 vs. 5.4%, p = 0.732) between the two groups. There was no mortality in both groups. The initial stone clearance rate showed no significant difference between the two groups (98.0 vs. 98.2%, p = 1.000), and the final stone clearance rate was 100% in both groups (p = 1.000). The stone recurrence rate had no significant difference between the two groups (2.0 vs. 2.4%, p = 1.000). The conversion rate was comparable between group A and group B (6.0 vs. 4.8%, p = 0.718).

CONCLUSIONS

LCBDE is a safe and feasible procedure for patients with previous upper abdominal surgery. The keys of this procedure are carefully separating the adhesions and clearly exposing the common bile duct, and using a variety of methods to remove the stones.

Biliary exploration via the left hepatic duct orifice versus the common bile duct in left-sided hepatolithiasis patients with a history of biliary tract surgery: A randomized controlled trial

BACKGROUND

Hepatectomy and additional common bile duct exploration are required for the treatment of left-sided hepatolithiasis (LSH).

METHODS

Eligible LSH patients (n = 62) scheduled for open left lateral segmentectomy or left hemihepatectomy with intraoperative biliary exploration via the left hepatic duct orifice (LHD group, n = 35) or the common bile duct (CBD group, n = 27) were retrospectively studied. T-tube insertion was performed on selected patients. Primary outcome measures included overall operative time, length of hospital stay, intraoperative complications, residual stones, and postoperative bile leaks.

RESULTS

There were no residual stones observed in the 2 groups. Ten patients in the CBD group received T-tube placement, whereas no patients in the LHD group received T-tube placement. There were more patients in the CBD group suffered intraoperative complications and postoperative bile leakage than LHD group (P < .05). The LHD group had a significantly shorter operative time and hospitalization than the CBD group (P < .05).

CONCLUSION

For left-sided hepatolithiasis patients with a history of biliary tract surgery, LHD cholangioscopy is an accessible technique that simplifies the operation procedure by avoiding choledochotomy and subsequent T-tube insertion, which results in lower complication rates as well as shorter operative duration and length of hospitalization.

Laparoscopic Exploration Can Salvage Recurrent Common Bile Duct Stone after Cholecystectomy

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

Strategies of minimally invasive treatment for intrahepatic and extrahepatic bile duct stones

Cholelithiasis is a kind of common and multiple diseases. In recent years, traditional laparotomy has been challenged by a minimally invasive surgery. Through literature review, the therapeutic method, effect, and complications of minimally invasive treatment of intrahepatic and extrahepatic bile duct stones by combining our practical experience were summarized as follows. (1) For intrahepatic bile duct stones, the operation may be selected by laparoscopic liver resection, laparoscopic common bile duct exploration (LCBDE), or percutaneous transhepatic cholangioscopy. (2) For concomitant gallstones and common bile duct stones, the surgical approach can be selected as follows: laparoscopic cholecystectomy (LC) combined with endoscopic sphincterotomy (EST) or endoscopic papillary balloon dilatation, LC plus laparoscopic transcystic common bile duct exploration, LC plus LCBDE, and T-tube drainage or primary suture. (3) For concomitant intrahepatic and extrahepatic bile duct stones, laparoscopic liver resection, choledochoscopy through the hepatic duct orifice on the hepatectomy cross section, LCBDE, EST, and percutaneous transhepatic cholangioscopic lithotripsy could be used. According to the abovementioned principle, the minimally invasive treatment approach combined with the surgical technique and equipment condition will be significant in improving the therapeutic effect and avoiding the postoperative complications or hidden dangers of intrahepatic and extrahepatic bile duct stones.

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

OBJECTIVE

To compare the efficacy, safety, and surgical outcomes of laparoscopic common bile duct exploration, endoscopic retrograde cholangiopancreatography, and open common bile duct exploration for treatment of common bile duct stones.

METHODS

In total, 210 patients were prospectively randomized into 3 groups: laparoscopic common bile duct exploration, endoscopic retrograde cholangiopancreatography, and open common bile duct exploration. The primary outcome measures were the common bile duct stone clearance rate and the complication rate. The secondary outcome measures were mortality, total costs, and length of hospital stay.

RESULTS

The success rates in the laparoscopic common bile duct exploration group (97.14%, 68 out of 70) and open common bile duct exploration group (98.57%, 69/70) were significantly higher than that in the endoscopic retrograde cholangiopancreatography group (85.71%, 60/70, both p < 0.05). The complication rates in the laparoscopic common bile duct exploration group (2.86%, 2/70) and open common bile duct exploration group (1.43%, 1/70) were significantly lower than that in the endoscopic retrograde cholangiopancreatography group (14.29%, 10/70, both p < 0.05). The success rate and complication rate were not significantly different between the laparoscopic common bile duct exploration group and open common bile duct exploration group (both p > 0.05).

CONCLUSION

Laparoscopic common bile duct exploration provides an alternative therapeutic approach that was safer and more reliable, allowed for earlier recovery, and provided more cost-effective treatment of common bile duct stones.

Three modalities on management of choledocholithiasis: A prospective cohort study

BACKGROUND

Choledocholithiasis can be managed by endoscopic retrograde cholangiopancreaticography/endoscopic sphincterotomy (ERCP/EST) or laparoscopic common bile duct (CBD) exploration by transcystic (TC) or transductal (TD) stone extraction.

OBJECTIVE

The aim of this study was to evaluate the safety and effectiveness of common bile duct stones extraction by ERCP/EST, TC approach and TD approach for choledocholithiasis, with specific emphasis on ERCP/EST, TC approach versus TD approach.

METHODS

Between January 2011 and June 2014, a total of 161 patients were scheduled for two-stage (preoperative ERCP/EST followed by cholecystectomy, ERCP group, n = 52)or single-stage (laparoscopic exploration of the CBD combined with cholecystectomy, n = 109) treatment for choledocholithiasis with concomitant cholecystitis. Laparoscopic common bile duct exploration was performed by TC approach (TC group, n = 63)or TD approach (TD group, n = 46). T-tube insertion was performed in selected patients. Patients were regularly followed up at bimonthly intervals or more frequently in presence of any symptom. Primary outcomes measures included length of hospital stay, successful bile duct clearance, postoperative/procedural morbidity and mortality.

RESULTS

Successful bile duct clearance was 100.0% in TD group, 93.7% in TC group and 92.3% in ERCP group. 4 cases in the TC group and 4 cases in the ERCP group required an extra choledocholithotomy due to impacted stones. 9 patients underwent T-tube drainage in TD group comparing to 1 case in ERCP group and no cases in TC group. Comparing to TC group, there was more postoperative morbidity in TD and ERCP group. Bile leaks were more frequent in TD group (8.7%) than TC (3.2%) and ERCP group (3.8%), which prolonged hospitalization in TD group than TC and ERCP group. 2 patients in ERCP group suffered duodenal perforation and one of them died because of the complication. However, total procedural morbidity was 0% in TC and TD group.

CONCLUSION

TD stone extraction has a higher stone clearance but with a higher risk of bile leaks. Procedural morbidity is more often happened in ERCP/EST, which may result in serious consequences. TC stone extraction, which seems an effective approach with lower complication rates, is accessible techniques simplifying the operation procedure by avoiding choledocholithotomy and subsequent T-tube insertion.

Strategy of minimally invasive surgery for patients with intrahepatic and extrahepatic bile duct stones

Cholelithiasis is a common, frequently occurring disease. In recent years, traditional laparotomy is challenged by minimally invasive surgery. Through literature review combined with our practical experience based on the present situation of minimally invasive treatment of intrahepatic and extrahepatic bile duct stones, a strategy for improving the effectiveness of minimally invasive treatment is discussed as follows: (1) For intrahepatic bile duct stones, laparoscopic hepatectomy, laparoscopic common bile duct exploration (LCBDE), or percutaneous transhepatic cholangioscopy can be chosen according to the indications; (2) For concomitant gallstones and common bile duct stones, laparoscopic cholecystectomy (LC) + endoscopic sphincterotomy (EST) or endoscopic papillary balloon dilatation (EPBD), LC + laparoscopic transcystic common bile duct exploration (LTCBDE), LC + LCBDE + T tube drainage or primary suture can be chosen according to the indications; (3) For concomitant intrahepatic and extrahepatic bile duct stones, laparoscopic liver resection, choledochoscopy through the hepatic duct orifice on the hepatectomy cross-section, LCBDE, EST, or percutaneous transhepatic cholangioscopic lithotripsy could be chosen according to the indications. Reasonable selection of minimally invasive treatments according to this strategy is of great significance to improve the therapeutic effect for intrahepatic and extrahepatic bile duct stones.

Management of impacted common bile duct stones during a laparoscopic procedure: A Retrospective Cohort Study of 377 Consecutive Patients

INTRODUCTION

To explore the techniques for managing impacted common bile duct (CBD) stones during laparoscopic common bile duct exploration (LCBDE).

METHODS

We retrospectively analyzed 377 consecutive patients undergoing LCBDE from January 2008 to June 2015. Group 1 was defined as patients with impacted CBD stones. Group 2 included patients without impacted CBD stones. The outcomes of LCBDE were compared between the two groups.

RESULTS

There were 65 patients in Group 1 and 312 patients in Group 2. The incidence of jaundice, abnormal liver function tests, cholangitis and pancreatitis was higher in Group 1. Forty-one patients with small impacted CBD stones were managed using the tipless Nitinol basket. Seventeen patients with large impacted CBD stones and 7 patients with small impacted CBD stones underwent laser lithotripsy via choledochoscopy. None of the patients in Group 1 was converted to open procedures for impacted CBD stones. Operation duration was 13.6 min longer in Group 1 (133.2 min). Postoperative hospital stay was significantly longer in Group 1 (9.7 ± 2.5 d) than in Group 2 (6.3 ± 1.8 d). There was no difference in the overall postoperative complication rate, retained stone rate, and recurrence rate between the two groups.

CONCLUSION

Rational utilization of laser lithotripsy and an appropriate basket in LCBDE may avoid conversion to open procedures in patients with impacted CBD stones.

Innovative technique of needlescopic grasper-assisted single-incision laparoscopic common bile duct exploration: A comparative study

AIM: To investigate the safety and feasibility of needlescopic grasper-assisted single-incision laparoscopic common bile duct exploration (nSIL-CBDE) by comparing the surgical outcomes of this technique with those of conventional laparoscopic CBDE (CL-CBDE).

METHODS: We retrospectively analyzed the clinical data of patients who underwent CL-CBDE or nSIL-CBDE for the treatment of common bile duct (CBD) stones between January 2000 and December 2014. For performing nSIL-CBDE, a needlescopic grasper was also inserted through a direct puncture below the right subcostal line after introducing a single-port through the umbilicus. The needlescopic grasper helped obtain the critical view of safety by retracting the gallbladder laterally and by preventing crossing or conflict between laparoscopic instruments. The gallbladder was then partially dissected from the liver bed and used for retraction. CBD stones were usually extracted through a longitudinal supraduodenal choledochotomy, mostly using flushing a copious amount of normal saline through a ureteral catheter. Afterward, for the certification of CBD clearance, CBDE was performed mostly using a flexible choledochoscope. The choledochotomy site was primarily closed without using a T-tube, and simultaneous cholecystectomies were performed.

RESULTS: During the study period, 40 patients underwent laparoscopic CBDE. Of these patients, 20 underwent CL-CBDE and 20 underwent nSIL-CBDE. The operative time for nSIL-CBDE was significantly longer than that for CL-CBDE (238 ± 76 min vs 192 ± 39 min, P = 0.007). The stone clearance rate was 100% (40/40) in both groups. Postoperatively, the nSIL-CBDE group required less intravenous analgesic (pethidine) (46.5 ± 63.5 mg/kg vs 92.5 ± 120.1 mg/kg, P = 0.010) and had a shorter hospital stay than the CL-CBDE group (3.8 ± 2.0 d vs 5.1 ± 1.7 d, P = 0.010). There was no significant difference in the incidence of postoperative complications between the two groups.

CONCLUSION: The results of this study suggest that nSIL-CBDE could be safe and feasible while improving cosmetic outcomes when performed by surgeons trained in conventional laparoscopic techniques.