Laparoscopic versus endoscopic management of choledocholithiasis in patients undergoing laparoscopic cholecystectomy: a meta-analysis

TAVAC: choledochoscopy disposable scopes, and the single-stage vs. two-stage approach to choledocholithiasis

BACKGROUND

Previous studies have been published evaluating the benefits and drawbacks of clearing the common bile duct of stones using a single-stage approach (LCBDE + LC) versus a two-stage approach (ERCP followed by LC). These studies have demonstrated that a single-stage approach offers similar outcomes and morbidities as a two-stage approach, with the added benefit of a lower cost and shorter length of stays. However, it is significant we understand why LCBDE is not commonly performed currently and also the lapse in surgical trainee exposure and competence in LCBDE. This paper aims to address the lapse in surgical trainee exposure to LCBDE, evaluate the scopes currently available to perform LCBDE, and review current data evaluating the risks and benefits of single-stage versus two-stage approaches to.

METHODS

We utilized PubMed to analyze all publications related to the various disposable scopes utilized to perform choledochoscopy. We also discuss the need for disposable scopes and how this new market niche is transforming the choledochoscopy space.

RESULTS

We analyzed the data related to single-stage and two-stage approach to choledocholithiasis. We noted an overall shorter length of stay and also decreased costs in favor of a single-stage approach.

CONCLUSION

A single-stage LCBDE is the most cost-effective treatment option for choledocholithiasis in patients with choledocholithiasis undergoing a cholecystectomy. In addition, single-stage approach is associated with shorter length of stay. Knowledge of the available choledochoscopes and tools available to surgeons to perform choledochoscopy is significant. The evidence does support the use of disposable choledochoscope from a cost and cross-contamination perspective. Additionally, efforts should be made to incorporate LCBDE into the teaching paradigm of surgical training programs.

Laparoscopic common bile duct exploration with primary closure is preferred for selected elderly individuals with choledocholithiasis

Background

Laparoscopic common bile duct exploration with primary closure (LCBDE-PC) exhibits more benefits than other surgeries for patients with choledocholithiasis. It remains unclear whether it is feasible for and beneficial to elderly individuals. This study aimed to clarify and stratify elderly patients who would benefit from LCBDE-PC.

Methods

A retrospective study of 1240 patients with choledocholithiasis who underwent laparoscopic procedures between 2011 and 2019 was conducted. Patients were divided into the young group (<65 years old, n = 708) and the elderly group (≥65 years old, n = 532). Perioperative outcomes were compared between the two groups.

Results

Laparoscopic common bile duct exploration with primary closure was successfully performed in 90.20% of the elderly and 94.20% of the young. No significant differences were observed between the two groups regarding reoperation, postoperative bile leakage, residual stones, drainage removal, and postoperative mortality. Compared with the young, the elderly had longer postoperative hospital stay (p = 0.035) and delayed postoperative eating time (p = 0.036) in the matched cohort. Independent risk factors for failed LCBDE-PC were preoperative pancreatitis (p = 0.018), year of the surgeon's experience (p = 0.008), preoperative C-reactive protein level (p = 0.034), preoperative total bilirubin (p = 0.021), impacted common bile duct (CBD) stones (p = 0.006), blood loss (p = 0.001), and edema of the CBD (p = 0.001). A novel nomogram for predicting failed LCBDE-PC in elderly individuals exhibited a sufficient discriminative ability according to the estimated area under the curve (AUC) of 0.869 (95% CI: 0.817-0.921, p < 0.01).

Conclusion

Laparoscopic common bile duct exploration with primary closure is safe, feasible, and effective for elderly individuals with choledocholithiasis. Elderly patients with a high risk of failed LCBDE-PC should be cautious of undergoing LCBDE-PC.

[Modern minimally invasive technologies for the treatment of cholelithiasis]

Surgical community has not yet reached any consensus on the adequate treatment of gallstone disease with combined stones of the gallbladder and bile ducts. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic papillosphincterotomy (EPST) followed by laparoscopic cholecystectomy (LCE) have been considered the optimal treatment method for the past thirty years. Thanks to improvement of technologies and experience in laparoscopic surgery, many centers in the world offer simultaneous treatment of cholecystocholedocholithiasis, i.e. LCE and laparoscopic choledocholithotomy. Transcystical and transcholedochal extraction of calculi from the common bile duct is the most common. Intraoperative cholangiography and choledochoscopy are used to assess extraction of calculi while T-shaped drainage, biliary stent and primary suture of common bile duct are used to complete choledocholithotomy. Laparoscopic choledocholithotomy is associated with certain difficulties, requires some experience in choledochoscopy and intracorporeal suturing of common bile duct. There are many unresolved issues regarding the choice of laparoscopic choledocholithotomy technique depending on the number and dimensions of stones, diameter of cystic duct and common bile duct. The authors analyze literature data on the role of modern minimally invasive interventions in the treatment of gallstone disease.

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

Aim

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

Patients and Methods

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

Results

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

Conclusion

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

Contemporary management of concomitant gallstones and common bile duct stones: a survey of Spanish surgeons

BACKGROUND

Concomitant gallstones and common bile duct stones (CBDS) is a relatively frequent presentation. The optimal treatment remains controversial and the debate persists between two strategies. The one-stage approach: laparoscopic cholecystectomy with laparoscopic common bile duct exploration (LCBDE) has been shown to be equally safe and more cost-effective than the more traditional two-stage approach: endoscopic retrograde cholangiography followed by laparoscopic cholecystectomy (ERCP + LC). However, many surgeons worldwide still prefer the two-stage procedure. This survey evaluated contemporary management of CBDS in Spain and assessed the impact of surgeon and hospital factors on provision of LCBDE.

METHODS

A 25-item, web-based anonymous survey was sent to general surgeons members of the Spanish Surgeons Association. Descriptive statistics were applied to summarize results.

RESULTS

Responses from 305 surgeons across 173 Spanish hospitals were analyzed. ERCP is the initial approach for preoperatively suspected CBDS for 86% of surgeons. LCBDE is the preferred method for only 11% of surgeons and only 11% treat more than 10 cases per year. For CBDS discovered intraoperatively, 59% of respondents attempt extraction while 32% defer to a postoperative ERCP. The main reasons cited for not performing LCBDE were lack of equipment, training and timely availability of an ERCP proceduralist. Despite these barriers, most surgeons (84%) responded that LCBDE should be implemented in their departments.

CONCLUSIONS

ERCP was the preferred approach for CBDS for the majority of respondents. There remains limited use of LCBDE despite many surgeons indicating it should be implemented. Focused planning and resourcing of both training and operational demands are required to facilitate adoption of LCBDE as option for patients.

Coledocolitiasis y exploración laparoscópica de la vía biliar. Un estudio de cohorte

Introducción. La coledocolitiasis es la presencia de cálculos en las vías biliares. En la mayoría de los casos se trata mediante la colangio pancreatografía retrógrada endoscópica y menos comúnmente por intervención quirúrgica laparoscópica. El objetivo de este estudio fue describir una cohorte retrospectiva de pacientes sometidos a exploración laparoscópica de la vía biliar. Métodos. Se incluyeron pacientes intervenidos entre los años 2014 y 2018, en dos instituciones de nivel III en Cali, Colombia, referidos para valoración por cirugía hepato-biliar, por dificultad para la extracción de los cálculos por colangio pancreatografia retrograda endoscópica, debido al tamaño, la cantidad, o la dificultad para identificar o canular la papila duodenal. Resultados. De los 100 pacientes incluidos, se encontró que el 72 % fueron mujeres, con rango de edad entre 14 y 92 años. Al 39 % de los pacientes se les extrajo un solo cálculo y al 16 % 10 cálculos. Un 12 % presentaron cálculos gigantes (mayores de 2,5 cm de ancho) y un 44 % presentaron litiasis múltiple. Al 69 % de los pacientes se les realizó colecistectomía. El porcentaje de éxito de limpieza de la vía biliar por laparoscopia fue del 95 %. Discusión. La exploración laparoscópica de la vía biliar es una técnica posible, reproducible, segura y con excelentes resultados para el manejo de la coledocolitiasis.

Quality of Life Outcomes Following Single-stage Laparoscopic Common Bile Duct Exploration Versus 2-stage Endoscopic Sphincterotomy Followed by Laparoscopic Cholecystectomy in Management of Cholelithiasis With Choledocholithiasis

INTRODUCTION

With various studies in the literature showing laparoscopic common bile duct (CBD) exploration to have equal or similar results when compared with endoscopic sphincterotomy (EST) clearance, decision-making in regard to the treatment modality to be used may become debatable. Thus, quality of life (QoL) data may assist both the patient and the clinician in deciding the management of the disease. The present prospective randomized trial was undertaken to compare QoL of patients undergoing treatment with these 2 approaches.

METHODOLOGY

The study was conducted March 1, 2013, to September 31, 2016. Consecutive patients with CBD stones were randomized to either laparoscopic CBD exploration with cholecystectomy (group I) and EST followed by laparoscopic cholecystectomy (group II). Diagnosis was confirmed preoperatively using magnetic resonance cholangiopancreatography and/or endoscopic ultrasound. QoL scores were assessed by World Health Organization Quality of Life-Brief Version (WHOQOL-BREF), European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire C30 (EORTC QLQ-C30), and Hospital Anxiety and Depression Scale (HADS) questionnaires.

RESULTS

A total of 77 patients with concomitant gallstones and CBD stones were finally recruited (38 patients in group I and 39 patients in group II). The demographic and clinical profiles were similar in both the groups. On EORTC QLQ-C30 questionnaire, there was significant improvement in physical, emotional, and role functioning in both the groups (P<0.01) with no intergroup variation preprocedure or postprocedure. Patients in both the groups reported similar WHOQOL scores with significant improvement postprocedure and minimal intergroup variation. Both the depression and anxiety scores on HADS were comparable between the 2 groups preoperatively and at 3 months postoperatively.

CONCLUSION

Single-stage management of patients with gallbladder and CBD stones and EST followed by laparoscopic cholecystectomy were similar in terms of improvement in QoL.

Transductal versus transcystic laparoscopic common bile duct exploration: an institutional review of over four hundred cases

BACKGROUND

Many studies have failed to demonstrate significant differences between single- and two-staged approaches for the management of choledocholithiasis with concomitant gallstones in terms of post-operative morbidity. However, none of these studies paid specific attention to the differences between the methods of accessing the bile duct during laparoscopy. The aim of this study was to report outcomes of transcystic versus transductal laparoscopic common bile duct exploration (LCBDE) from our experience of over four hundred cases.

METHODS

Retrospective review of 416 consecutive patients who underwent LCBDE at a single-centre between 1998 and 2018 was performed. Data collected included pre-operative demographic information, medical co-morbidity, pre-operative investigations, intra-operative findings (including negative choledochoscopy rates, use of holmium laser lithotripsy and operative time) and post-operative outcomes.

RESULTS

Transductal LCBDE via choledochotomy was achieved in 242 patients (58.2%), whereas 174 patients (41.8%) underwent transcystic LCBDE. Stone clearance rates, conversion to open surgery and mortality were similar between the two groups. Overall morbidity as well as minor and major post-operative complications were significantly higher in the transductal group. The main surgery-related complications were bile leak (5.8% vs 1.1%, p = 0.0181) and pancreatitis (7.4% vs 0.6%, p = 0.0005). Median length of post-operative stay was also significantly greater in the transductal group.

CONCLUSION

This study represents the largest single study to date comparing outcomes from transcystic and transductal LCBDE. Where possibly, the transcystic route should be used for LCBDE and this approach can be augmented with various techniques to increase successful stone clearance and reduce the need for choledochotomy.

Holmium laser lithotripsy improves the rate of successful transcystic laparoscopic common bile duct exploration

Purpose

Transcystic laparoscopic common bile duct exploration (LCBDE) seems safer than transductal LCBDE and is associated with fewer biliary complications. It has traditionally been limited to smaller bile duct stones however. This study aimed to assess the ability of laser-assisted bile duct exploration by laparoendoscopy (LABEL) to increase the rate of successful transcystic LCBDE in patients with bile duct stones at the time of laparoscopic cholecystectomy.

Methods

Patients undergoing LCBDE between 2014 and 2018 were retrospectively analysed. Baseline demographic and medical characteristics were recorded, as well as intra-operative findings and post-procedure outcomes. Standard LCBDE via the transcystic route was initially attempted in all patients, and LABEL was only utilised if there was failure to achieve transcystic duct clearance. The transductal route was utilised for failed transcystic extraction.

Results

One hundred and seventy-nine consecutive patients underwent LCBDE; 119 (66.5%) underwent unaided transcystic extraction, 29 (16.2%) required LABEL to achieve transcystic extraction and 31 (17.3%) failed transcystic extraction (despite the use of LABEL in 7 of these cases) and hence required conversion to transductal LCBDE. As such, LABEL could be considered to increase the rate of successful transcystic extraction from 66.5% (119/179) to 82.7% (148/179). Patients requiring LABEL were however more likely to experience major complications (CD III–IV 5.6% vs 0.7%, p = 0.042) although none were specifically attributable to the laser intra-operatively.

Conclusions

LABEL is an effective adjunct to LCBDE that improves the rate of successful transcystic extraction.

One-stage laparoscopic procedure versus two-stage procedure in the management of common bile duct stones in patients aged 75 and more

INTRODUCTION

The management strategy for common bile duct stones (CBD) in patients over 75years is a real challenge that requires balancing the efficacy of a multiplicity of procedures against their own morbidity. The objective is to compare one-stage surgical treatment versus the two-stage combination of endoscopy and surgery in terms of efficacy of clearing the CBD of stones and the morbidity and mortality in elderly patients.

MATERIAL AND METHODS

This study included eighty-two patients over 75years of age with symptomatic CBD stones who presented between 2010 and 2017. Patients were treated either by one-stage surgery alone (S group, n=40) or by sequential endoscopy and surgery (ES group, n=42).

RESULTS

Immediate and 30-day mortality, morbidity and duration of hospitalization were comparable. The failure rate for clearing CBD lithiasis was significantly higher in the ES group (26.2% vs. 7.5%, P=0.038, 95% CI). In multivariate analysis, two-stage treatment and multiple CBD stones were associated with a significantly higher risk of failure. Fewer anesthetic procedures were needed in the S group. Twelve patients (14.4%) had multiple stones packing the CBD (>3 stones); four were treated with choledocho-duodenal anastomosis and eight with endoscopic sphincterotomy and stone removal with 100% and 50% efficacy, respectively.

CONCLUSION

The "surgery alone" attitude compared to 2-stage endoscopic and surgical management is associated with better efficacy in terms of clearing the CBD of lithiasis and requires fewer anesthetic procedures in elderly subjects while being comparable in terms of morbidity and mortality. In patients whose CBD is packed with multiple stones, choledocho-duodenal anastomosis is an alternative to endoscopy for management of choledocholithiasis.

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

Background

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

Methods

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

Results

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

Conclusions

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

Choledocholithiasis recurrence following laparoscopic common bile duct exploration

INTRODUCTION

Choledocholithiasis may be treated following an endoscopic approach or by laparoscopic common bile duct exploration (LCBDE). Stone recurrence following endoscopic management has been extensively investigated. We analyze the risk factors associated with stone recurrence following LCBDE.

METHODS

Patients who underwent LCBDE from February 2004 to July 2016 were examined in an univariate and multivariate analysis to assess the association of stone recurrence with the following variables: gender; age; hepatopathy; dyslipidemia, obesity or diabetes mellitus; previous abdominal surgery; presence of cholecystitis, cholangitis or pancreatitis; preoperative liver function tests, number of retrieved stones; method of common bile duct clearance and closure; presence of impacted or intrahepatic stones; conversion to open surgery and postoperative morbidity.

RESULTS

A total of 156 patients were included. Recurrence rate for choledocholithiasis was 14.1% with a mean time to recurrence of 38.18 month. Age was the only independent risk factor for stone recurrence at univariate and multivariate analysis. No patient aged under 55 years developed new common bile duct stones, and 86.4% of the recurrences occurred in patients aged above 65.

CONCLUSIONS

Age is the only independent risk factor associated to choledocholithiasis recurrence following LCBDE. Different mechanism in common bile duct stone development may be present for younger and older patients.

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.

Efficacy of fibrin-sealants in reducing biliary leakage following laparoscopic common bile duct exploration

INTRODUCTION

In spite of the acquired experience with laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis management, there is still a risk of biliary leakage of 5% to 15% following choledochotomy closure. We evaluate the usefulness of fibrin-collagen sealants to reduce the incidence of biliary fistula after laparoscopic choledochorrhaphy.

METHODS

We report a retrospective analysis of 96 patients undergoing LCBDE from March 2009 to March 2017, whose closure of the bile duct was completed by antegrade stenting and choledochorraphy or by performing a primary suture. The study population was divided into two groups according to whether they received a collagen-fibrin sealant covering the choledochorrhaphy or not, analyzing the incidence of postoperative biliary fistula in each group.

RESULTS

Thirty-nine patients (41%) received a fibrin-collagen sponge while the bile duct closure was not covered in the remaining 57 patients (59%). The incidence of biliary fistula was 7.7% (3 patients) in the first group and 14% (8 patients) in the second group (P=.338). In patients who underwent primary choledochorraphy, the fibrin-collagen sealant reduced the incidence of biliary leakage significantly (4.5% vs. 33%, P=.020), which was a protective factor with an odds ratio of 10.5.

CONCLUSION

Fibrin-collagen sealants may decrease the incidence of biliary fistula in patients who have undergone primary bile duct closure following LCBDE.

Comparative Study of Three Bile Duct Closure Methods Following Laparoscopic Common Bile Duct Exploration for Choledocholithiasis

BACKGROUND

There are three choledochotomy closure methods available following laparoscopic common bile duct exploration: T-tube insertion, antegrade stenting, and primary choledochorrhaphy. We reviewed the experience of 12 years at our center searching for the optimal closure technique.

METHODS

We analyzed retrospectively 146 patients that underwent one of the three closure methods from February 2004 to March 2016. Hospital stay, need for readmission, incidence of early and long-term complications, and biliary leakage development and their clinical impact were determined for each technique.

RESULTS

Hospital stay was more prolonged, and need for readmission was higher in the T-tube group. Nine patients of the T-tube group (17.3%), 5 patients (8.6%) of the antegrade stenting group, and 1 patient of the primary suture group (2.8%) developed Dindo-Clavien ≥3 complications (P = .076). The incidence of biliary leakage was 3.8%, 8.6%, and 16.7% for the T-tube group, antegrade stenting group, and primary suture group, respectively. There was no grade C biliary fistula in the primary suture group, and all grade B leaks in these patients were only due to prolonged duration. The T-tube removal caused adverse events in 21.1% of the patients, and complications directly related with stents occurred in 9.6%.

CONCLUSION

Antegrade stents or T-tube insertion do not provide any added value for choledochotomy closure but are charged with specific morbidity. On the contrary, despite biliary leaks being more frequent after primary suture, they are of little clinical consequence and may be managed on an outpatient basis.

A 23 year experience with laparoscopic common bile duct exploration

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) during laparoscopic cholecystectomy (LC) is as effective as two-stage endo-laparoscopic treatment, but with shorter hospital stay, lower cost and recurrent stone rate. Aim of this paper was to report the authors' experience with LCBDE during LC.

METHODS

A retrospective analysis of patients who underwent LCBDE for ductal stones was performed. Recurrent stones were defined as CBD stones detected beyond 6 months from the procedure. Postoperative biliary stricture was defined as a symptomatic reduction of CBD diameter.

RESULTS

Out of 3444 patients who underwent LC, 384 (11%) had CBD stones treated by trans-cystic duct exploration [214 (6%) patients, TCD-CBDE] or choledochotomy [170 (5%) patients, C-CBDE]. For TCD-CBDE and C-CBDE, mean operative time was 127 ± 69 and 191 ± 74 min, respectively. Major morbidity rate was 3% (n = 6) in TCD-CBDE and 6% (n = 11) in C-CBDE. The incidence of residual stones was 5% (n = 20) and complete ductal clearance rate was 95% (n = 364). After long-term follow-up (mean 189 ± 105 months) the recurrent stone rate was 2%.

DISCUSSION

In expert centers, LCBDE during LC is safe and effective with low short and long term morbidity rates.

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.

Concurrent Percutaneous Transhepatic Papillary Balloon Dilatation Combined with Laparoscopic Cholecystectomy for the Treatment of Gallstones with Common Bile Duct Stones

OBJECTIVE

To evaluate the clinical effectiveness and safety of percutaneous transhepatic papillary balloon dilatation (PPBD) combined with laparoscopic cholecystectomy (LC) for the treatment of gallstones with common bile duct stones.

MATERIALS AND METHODS

From February 2012 to January 2013, 65 patients (31 males and 34 females) who had gallstones with common bile duct stones were divided into two groups: endoscopic papillary balloon dilatation (EPBD)+LC (n = 40 cases) and PPBD+LC (n = 25 cases). The maximum transverse diameter of common bile duct stoned was 15 mm. White blood cell count and serum amylase level were measured at 12 hours and 72 hours after the operation, and operation time, time of gastrointestinal function recovery, and hospitalization time were analyzed.

RESULTS

No case in either group was converted to open surgery. The stones were successfully pushed out into the duodenum in all patients of both groups. One case of postoperative pancreatitis (2.5%) and 5 cases of hyperamylasemia (12.5%) occurred among the 40 patients in the EPBD+LC group. In contrast, no case of postoperative pancreatitis and 2 cases of hyperamylasemia (8%) occurred among the 25 patients in the PPBD+LC group. The serum amylase level at 12 hours postoperatively was statistically significantly different (307 ± 39.94 IU/L in the EPBD+LC group and 193 ± 30.78 IU/L in the PPBD+LC group; P < .05). There were no significant differences between the two groups in operative time, postoperative gastrointestinal function recovery time, or hospital stay time (P > .05). During follow-up of 2 years, 1 case of recurrence for common bile duct stones was discovered and was treated successfully with EPBD repeatedly.

CONCLUSIONS

PPBD combined with LC simultaneously is an alternative effective and safe procedure for the treatment of gallstones and bile duct stones, especially for those patients who are unsuitable for endoscopic treatment.

Role of laparoscopic common bile duct exploration in the management of choledocholithiasis

Surgical fraternity has not yet arrived at any consensus for adequate treatment of choledocholithiasis. Sequential treatment in the form of pre-operative endoscopic retrograde cholangio-pancreatography followed by laparoscopic cholecystectomy (LC) is considered as optimal treatment till date. With refinements in technique and expertise in field of minimal access surgery, many centres in the world have started offering one stage management of choledocholithiasis by LC with laparoscopic common bile duct exploration (LCBDE). Various modalities have been tried for entering into concurrent common bile duct (CBD) [transcystic (TC) vs transcholedochal (TD)], for confirming stone clearance (intraoperative cholangiogram vs choledochoscopy), and for closure of choledochotomy (T-tube vs biliary stent vs primary closure) during LCBDE. Both TC and TD approaches are safe and effective. TD stone extraction is involved with an increased risk of bile leaks and requires more expertise in intra-corporeal suturing and choledochoscopy. Choice depends on number of stones, size of stone, diameter of cystic duct and CBD. This review article was undertaken to evaluate the role of LCBDE for the management of choledocholithiasis.

Results of Medium Seventeen Years' Follow-Up after Laparoscopic Choledochotomy for Ductal Stones

Introduction. In a previously published article the authors reported the long-term follow-up results in 138 consecutive patients with gallstones and common bile duct (CBD) stones who underwent laparoscopic transverse choledochotomy (TC) with T-tube biliary drainage and laparoscopic cholecystectomy (LC). Aim of this study is to evaluate the results at up to 23 years of follow-up in the same series. Methods. One hundred twenty-one patients are the object of the present study. Patients were evaluated by clinical visit, blood assay, and abdominal ultrasound. Symptomatic patients underwent cholangio-MRI, followed by endoscopic retrograde cholangiopancreatography (ERCP) as required. Results. Out of 121 patients, 61 elderly patients died from unrelated causes. Fourteen patients were lost to follow-up. In the 46 remaining patients, ductal stone recurrence occurred in one case (2,1%) successfully managed by ERCP with endoscopic sphincterotomy. At a mean follow-up of 17.1 years no other patients showed signs of bile stasis and no patient showed any imaging evidence of CBD stricture at the site of choledochotomy. Conclusions. Laparoscopic transverse choledochotomy with routine T-tube biliary drainage during LC has proven to be safe and effective at up to 23 years of follow-up, with no evidence of CBD stricture when the procedure is performed with a correct technique.