Outcomes of Laparoscopic vs Open Common Bile Duct Exploration: Analysis of the NSQIP Database

Changes in the Management of Common Bile Duct Stones: 1980 to Date

OBJECTIVE

To compare the results of treating patients with common bile duct (CBD) stones by endoscopic sphincterotomy (ES), surgical exploration, or a combination of ES and surgical CBD exploration (the rendezvous technique).

METHODS

A narrative review of the literature.

SUMMARY OF DATA

Before 1990, 17 cohort studies indicated that ES cleared CBD stones in 92.0% of patients, with a mortality rate of 1.5%. Surgery removed CBD stones in 90.2% of patients, with a 2.1% mortality rate. A single randomized controlled trial in 1987 showed that ES removed CBD stones in 91% of 55 patients, with a 3.6% mortality rate and a 27% complication rate, whereas surgical CBD exploration removed CBD stones in 92%, with a 1.8% mortality rate and a 22% complication rate. Since 1991, 26 randomized controlled trials have shown that laparoscopic-ES rendezvous is as effective as ES alone and laparoscopic surgery alone but is associated with fewer complications, a reduced need for additional procedures, and a shorter hospital stay.

CONCLUSIONS

A laparoscopic-ES rendezvous appears to be the optimal approach to the treatment of CBD stones in younger and fit patients. The choice between ES alone and laparoscopic-ES rendezvous in older or high-risk patients remains uncertain.

Learning Curve of Laparoscopic Common Bile Duct Exploration: A Systematic Review

Background: Single-stage laparoscopic common bile duct exploration (LCBDE) with cholecystectomy has superior outcomes over two-stage endoscopic retrograde cholangiopancreatogram with interval cholecystectomy. With decreasing trend of LCBDE, this study aims to summarize the literature on learning curve (LC) in LCBDE. Materials and Methods: PubMed, Embase, Scopus, and the Cochrane Library were systematically searched for articles from inception to June 3, 2022 (PROSPERO Ref No: CRD42022328451). Basic clinical demographics were collected. Poisson means (95% confidence interval [95% CI]) was used to determine the number of cases required to surmount the LC (N_LC). Results: Eight articles (n = 2071 patients) reported LC outcomes in LCBDE with mean study period of 5.9 ± 2.8 years. Majority of studies (62.5%) used arbitrary methods of LC analysis. Most common outcomes reported were complications (any or major) (75%), open conversion (75%), length of stay (62.5%), and operating time (50%). Mean CBD diameter was 11.3 ± 4.8 mm (n = 1122 patients). Incidence of acute cholecystitis, acute cholangitis, and acute pancreatitis were 13.9% (n = 232/1668), 7.8% (n = 128/1629), and 13.7% (n = 229/1668), respectively. Pooled analysis of all the included studies showed N_LC of 78.8 cases (95% CI: 71.9-86.3). Studies that used cumulative sum control chart analysis, nonarbitrary methods, and arbitrary-based LC had N_LC of 152.0 (95% CI: 135.4-170.1), 108.0 (95% CI: 96.6-120.4), and 49.7 (95% CI: 42.0-58.3) cases, respectively. N_LC was 37.0 cases (95% CI: 29.1-46.5) for single surgeon LC, and 99.8 cases (95% CI: 90.2-110.0) for institutional LC. Conclusion: Studies reporting N_LC in LCBDE are heterogeneous. Further studies should use nonarbitrary methods of analysis for patient-reported outcome measures and procedure-specific morbidity.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Laparoscopic choledochotomy and choledochoduodenostomy for the management of persistent common bile duct stones

Choledochotomy and choledochoduodenostomy were commonly used technique in the early twentieth century to extract bile duct stones. Endoscopic retrograde cholangiopancreatography and sphincterotomy revolutionised the scenario and is currently the preferred first-line option for managing choledocholithiasis. However, in certain circumstances, where endoscopic retrograde cholangiopancreatography fails, choledochotomy and choledochoduodenostomy are the only available options. We present the case of an 86-year-old female with a background of multiple previous presentations with biliary sepsis and ascending cholangitis requiring multiple endoscopic retrograde cholangiopancreatographies that failed to remove all stones in the common bile duct. She underwent a laparoscopic choledochotomy and choledochoduodenostomy that successfully resolved her common bile duct obstruction. Laparoscopic choledochotomy and choledochoduodenostomy reduce the length of hospital stay and help to minimise complications associated with open surgery.

Establishing consensus on the perioperative management of cholecystectomy in public hospitals: a Delphi study with an expert panel in Mexico

BACKGROUND

Several guidelines have put forward recommendations about the perioperative process of cholecystectomy. Despite the recommendations, controversy remains concerning several topics, especially in low- and middle-income countries. The aim of this study was to develop uniform recommendations for perioperative practices in cholecystectomy in Mexico to standardize this process and save public health system resources.

METHODS

A modified Delphi method was used. An expert panel of 23 surgeons anonymously completed two rounds of responses to a 29-item questionnaire with 110 possible answers. The consensus was assessed using the percentage of responders agreeing on each question.

RESULTS

From the 29 questions, the study generated 27 recommendations based on 20 (69.0%) questions reaching consensus, one that was considered uncertain (3.4%), and six (20.7%) items that remained open questions. In two (6.9%) cases, no consensus was reached, and no recommendation could be made.

CONCLUSIONS

This study provides recommendations for the perioperative management of cholecystectomy in public hospitals in Mexico. As a guide for public institutions in low- and middle-income countries, the study identifies recommendations for perioperative tests and evaluations, perioperative decision making, postoperative interventions and institutional investment, that might ensure the safe practice of cholecystectomy and contribute to conserving resources.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effects of laparoscopic vs open abdominal surgery on costs and hospital readmission rate and its effect modification by surgeons' case volume

BACKGROUND

Laparoscopy provides a minimally invasive alternative to open abdominal surgery. Current data describing its association with hospital readmission and costs in relation to surgeon laparoscopic case volume is limited to smaller databases and subsets of operations.

METHODS

This retrospective cohort study of 23,285 adult abdominal operations from 2007 to 2015 compares 30-day readmission rate and costs between laparoscopic and open abdominal operations and examines effect modification by surgeon laparoscopic case volume. Outcomes were all-cause hospital readmission within 30 days after discharge and index hospital admission cost.

RESULTS

All-cause hospital readmission rates were significantly lower after laparoscopic abdominal operations compared with open operations (adjusted odds ratio [aOR] 0.56, 95% CI 0.46-0.69, p < 0.001) with a difference in readmission risk attributable to laparoscopic approach of - 4.0% (95% CI - 5.4 to - 2.6%) in complete-case analysis. Among surgeons with a high laparoscopic case volume, the estimated difference in readmission risk through laparoscopy was magnified (- 5.8%, 95% CI - 7.5 to - 4.1%) compared to low surgeon laparoscopic case volume (- 2.9%, 95% CI - 4.8 to -1.1%, p for interaction = 0.005). The estimated difference in costs of the index hospital admission attributable to laparoscopic approach was - $3869 (95% CI - $4200 to - $3538; adjusted incidence rate ratio 0.77, 95% CI 0.75-0.79, p < 0.001). Laparoscopy was followed by significantly lower rates of readmissions related to gastrointestinal (aOR 0.68, 95% CI 0.55-0.85, p = 0.001), wound complications (infection: aOR 0.33, 95% CI 0.23-0.47, p < 0.001; non-infectious: aOR 0.47, 95% CI 0.30-0.74, p = 0.001), and malignancy (aOR 0.68, 95% CI 0.55-0.85, p < 0.001). The findings remain robust after multiple imputation and sensitivity analyses.

CONCLUSIONS

Laparoscopy versus open abdominal surgery is associated with reduced hospital readmissions related to malignancy, gastrointestinal, and wound complications. Effect modification by higher laparoscopy case volume argues for continued proliferation of laparoscopy in abdominal surgeries.

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.

Application of Barbed Sutures in Laparoscopic Common Bile Duct Exploration: A Retrospective Analysis

Common bile duct (CBD) suturing is a difficult procedure in laparoscopic CBD exploration. We sought to develop a simpler CBD suture technique using running barbed sutures. We retrospectively compared 2 suture techniques for CBD closure after T-tube placement. The barbed group comprised of 46 patients who underwent CBD closure using running barbed sutures, whereas the standard group comprised of 39 patients who received interrupted sutures. Mean CBD suturing time (6.2±0.9 vs. 12.2±1.1 min; P<0.001), total operating time (79.7±9.4 vs. 90.8±12.4 min; P<0.001), and hospital stay (6.1±1.8 vs. 7.0±1.7 d; P=0.024) were significantly shorter and less patients experienced leakage after T-tube flushing (P=0.041) with the barbed suture technique. There were 2 cases of postoperative bile leakage in the standard group, with no statistical significance. The running barbed suture technique is safe and effective for CBD closure, which can decrease operating time and risk of complications.

Choledocholithiasis: Treatment Options in a Tertiary Care Setup in Pakistan

Introduction Among patients with cholelithiasis, choledocholithiasis may also be present in about 18% of cases. They can be treated through various endoscopic, laparoscopic, and open surgical procedures. Objective The objective of this study was to determine the outcome of patients with choledocholithiasis being treated in our setup. Methods This descriptive case series was conducted at Holy Family Hospital, Rawalpindi, Pakistan over two years from January 2015 to December 2016. All patients with choledocholithiasis admitted to Surgical Unit 1 were included in this study. All patients underwent elective endoscopic retrograde cholangiopancreatography (ERCP). In patients with successful ERCP, laparoscopic or open cholecystectomy was performed at a later date. In patients in whom ERCP failed, open surgical clearance of the common bile duct (CBD), along with cholecystectomy, was done. Results A total of 200 cases of choledocholithiasis were admitted during the study period. Most of the participants (73%) in this study were female. Liver function tests were found to be deranged in 88 patients (44%) and normal in 112 patients (56%). At presentation, 3.5% (n=7) had concomitant acute biliary pancreatitis and 8% (n=16) had cholangitis. Successful ERCP followed by cholecystectomy was performed in 88.5% of cases. On the other hand, 11.5% (n=23) patients had failed ERCP due to impacted stones. They underwent open surgical procedures, i.e. 43.48% (n=10) had choledochotomies, 47.82% (n=11) had choledochoduodenostomies and 8.69% (n=2) had hepaticojejunostomies. No postoperative mortality was observed. However, anastomotic leaking occurred in 8.69% cases (n=2). Conclusion A two-staged procedure consisting of ERCP, followed by laparoscopic cholecystectomy, should be the first line of treatment for common bile duct (CBD) stones. In cases where ERCP fails, open surgical procedures still remain a relevant and a definitive option in resource-constrained setups.