A Comparison of the Relative Safety and Efficacy of Laparoscopic Choledochotomy with Primary Closure and Endoscopic Treatment for Bile Duct Stones in Patients with Cholelithiasis

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.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

GUIDELINE REGISTRATION NUMBER

IPGRP-2022CN170.

Stone removal by percutaneous papillary balloon dilatation for cystic duct and bile duct stones after cholecystectomy and distal gastrectomy with Roux-en-Y gastrojejunostomy

A 71-year-old woman was referred to our department for abdominal pain. She was diagnosed with acute obstructive cholangitis due to cystic duct and bile duct stones after cholecystectomy and Roux-en-Y gastrojejunostomy. Two years ago, the patient underwent endoscopic and laparoscopic treatment for cystic duct and bile duct stones, however, the stones remained. This time, she was treated with stone removal using percutaneous papillary balloon dilatation (PPBD). Large stones in the common hepatic and bile ducts were crushed by electrohydraulic lithotripsy and then pushed out into the duodenum through the dilated papilla of Vater using a balloon catheter covered with the sheath and cholangioscopy. Stone in the cystic duct was pulled to the common bile duct and pushed to the duodenum. Stone removal using PPBD is an excellent alternative for patients with cystic duct and bile duct stones unable to be treated with endoscopic or laparoscopic stone removal.

Comparison of intraoperative endoscopic retrograde cholangiopancreatography and laparoscopic common bile duct exploration combined with laparoscopic cholecystectomy for treating gallstones and common bile duct stones: a systematic review and meta-analysis

BACKGROUND

This study aimed to compare the efficacy and safety of laparoscopic cholecystectomy combined with intraoperative endoscopic retrograde cholangiopancreatography (LC-IntraERCP) and laparoscopic cholecystectomy combined with laparoscopic common bile duct exploration (LC-LCBDE) to determine which one-stage therapeutic strategy provides better outcomes for patients with gallstones and common bile duct stones.

METHODS

Cochrane Library, EMBASE, PubMed, and Web of Science databases were searched to identify eligible articles from the database inception to September 2020. The revised Cochrane risk of bias tools for randomized trials (RoB-2) and non-randomized interventions (ROBINS-I) was used to assess the quality of the included studies. The overall quality of evidence was assessed through the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool. The primary outcomes consisted of surgical success, retained stones, and overall postoperative complications, while secondary outcomes included postoperative bleeding, postoperative pancreatitis, postoperative bile leakage, conversion to laparotomy, and operative time.

RESULTS

Eight studies (four RCTs and four Non-RCTs with high quality) with 2948 patients were included. No significant difference was seen between the two groups regarding surgical success, overall postoperative complications, conversion to laparotomy, and operative time. The meta-analysis demonstrated that in the LC-IntraERCP group, the rate of retained stones (OR 0.51, 95% CI 0.28-0.91) and postoperative bile leakage were lower (OR 0.25, 95% CI 0.09-0.69), while in the LC-LCBDE group, postoperative bleeding (OR 5.24, 95% CI 1.65-16.65) and postoperative pancreatitis (OR 4.80, 95% CI 2.35-9.78) decreased.

CONCLUSIONS

LC-IntraERCP and LC-LCBDE exhibited similar efficacies when surgical success rate, overall postoperative complications, conversion to laparotomy, and operative time were compared. However, LC-IntraERCP is probably to be more effective in terms of lowering the rate of retained stones.

Laparoscopic common bile duct exploration versus intraoperative endoscopic retrograde cholangiopancreatography in patients with gallbladder and common bile duct stones: a meta-analysis

BACKGROUND

To compare the efficacy and safety of laparoscopic common bile duct exploration plus laparoscopic cholecystectomy (LCBDE + LC) with intraoperative endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy (IO-ERCP + LC) for the treatment of gallbladder and common bile duct (CBD) stones.

METHODS

We searched PubMed, Ovid, and Cochrane Library from their inception dates to April 2020, for studies that compared the efficacy and safety of LCBDE + LC with those of IO-ERCP + LC in patients with gallbladder and CBD stones. The technical success, morbidity, major morbidity, biliary leak, postoperative pancreatitis, conversion, retained stones, operative time, and postoperative hospital stay were compared between these two approaches.

RESULTS

Five randomized controlled trials involving 860 patients were evaluated. Overall, no significant difference was found between LCBDE + LC and IO-ERCP + LC regarding technical success, morbidity, major morbidity, and the conversion rate. Biliary leak and retained stones were significantly more prevalent in the LCBDE + LC group, while postoperative pancreatitis was significantly more prevalent in the IO-ERCP + LC group.

CONCLUSIONS

LCBDE + LC and IO-ERCP + LC have similar efficacy and safety in terms of technical success, morbidity, major morbidity, and conversion rate. However, LCBDE + LC is associated with a higher biliary leak rate, lower postoperative pancreatitis rate, and higher rate of retained stones.

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

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