Towards T-tube free laparoscopic bile duct exploration: a methodologic evolution during 300 consecutive procedures

ERCP findings provide further justification for a "surgery-first" mindset in choledocholithiasis

INTRODUCTION

Choledocholithiasis is most often managed in a two-procedure pathway including endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). In contrast, a single-stage, surgery-first approach consisting of LC, cholangiogram, and laparoscopic common bile duct exploration (LCBDE) is associated with reduced hospital stays and equivalent morbidity. Despite this, nationwide referral patterns heavily favor ERCP, obscuring those undergoing ERCP with obstructions amenable to simple intraoperative interventions. We hypothesized that most patients had endoscopic findings consistent with simple sludge or small-to-medium stones, which could have been cleared by basic LCBDE maneuvers.

METHODS

We retrospectively reviewed 294 patients > 18 years old who underwent preoperative ERCP for the management of suspected choledocholithiasis. Exclusion criteria included: failed ERCP, cholangitis, prior cholecystectomy, patient refusal of surgery, or medical conditions precluding surgical candidacy. Stone size was categorized as small (0-4 mm), medium (5-7 mm), and large (≥ 8 mm).

RESULTS

At the time of ERCP, 37 (20.1%) patients had sludge only, 96 (52.2%) had stones only, 42 (22.8%) had sludge and stones, and 9 (4.8%) had no stones. Of the 138 patients with any stones, 37 (26.8%) had small stones, 41 (29.7%) medium, 43 (31.2%) large, and 17 (12.3%) had uncharacterizable stones. Overall, 74.3% of patients had findings of sludge, stones (0-7 mm), or negative ERCP.

CONCLUSION

The majority of patients who underwent preoperative ERCP for suspected choledocholithiasis had findings that are amenable to simple intraoperative interventions. In fact, over a quarter of the patients had a negative ERCP, sludge, or small stones which would likely be cleared by flushing/glucagon precluding any further instrumentation. While large stones may require more advanced techniques, this represents a small percentage of patients. Surgery-first management for suspected choledocholithiasis can offer an efficient alternative for the majority of patients.

T‑tube versus internal drainage tube in laparoscopic common bile duct exploration

The 203 patients who underwent laparoscopic common bile duct exploration for choledocholithiasis were retrospectively analyzed. The patients were divided into internal drainage tube group (n=87) and T-tube group (n=116). Total bilirubin, direct bilirubin, alanine aminotransferase (AST), aspartate aminotransferase (ALT), the diameter of common bile duct, number of stones, operation time, intraoperative bleeding, postoperative hospital stay and postoperative complications were compared between the two groups. Possible influencing factors were selected as independent variables, and the operation mode was selected as the dependent variable for multifactor unconditional logistic regression analysis. There were no significant differences in the sex, age, total bilirubin, direct bilirubin, AST, ALT, operation time, intraoperative blood loss, postoperative hospital stay and postoperative biliary leaks between the two groups (P>0.05). The diameter of the common bile duct was smaller and the incidence of multiple stones in the common bile duct was lower in the internal drainage tube group compared with that in the T-tube group (P<0.05). The results of multifactor unconditional logistic regression analysis demonstrated that the diameter of the common bile duct and the number of stones in the common bile duct were associated with the operation mode as influencing factors. In conclusion, Patients with multiple stones in the common bile duct or with a wide diameter of the common bile duct are more likely to have T-tube placed rather than an internal drainage tube.

Upfront Laparoscopic Management of Common Bile Duct Stones: What Are the Risk Factors of Failure?

BACKGROUND

Treatment of common bile duct stones (CBDS) includes laparoscopic cholecystectomy (LC) with either laparoscopic common bile duct exploration (LCBDE) or perioperative endoscopic retrograde cholangiopancreatography (ERCP). The main objective of this study was to identify predictive factors for the failure of upfront and exclusive surgical treatment by LCBDE.

METHODS

This is a single-center, retrospective study on patients with CBDS and operated for LC between 2007 and 2019. The use of intra- or postoperative endoscopy for CBD clearance within 6 months after surgery was considered as failure of LCBDE. Predictors for the failure of LCBDE were investigated and outcomes were compared.

RESULTS

Among 222 operated patients, LCBDE was successfully performed in 173 patients (78%) and 49 (22%) required ERCP with sphincterotomy (intraoperative (n=29) or postoperative (n=20)). Independent risk factors for surgical failure were male sex (OR: 2.525 (1.111-5.738); p=0.027), anesthesia induction time ≥ 4 p.m. (OR: 4.858 (1.731-13.631); p=0.003), pediculitis (OR: 4.147 (1.177-14.606); p=0.027), and thin CDB < 4mm (OR: 11.951 (3.562-40.097), p< 0.0001). Age, ASA score, cystic anatomy, presence of cholecystitis, and the surgeon's experience were not identified as predictors for surgical failure. A general anesthesia number >1 (6% vs. 33%; p < 0.0001), length of initial stay (6 [1-42] vs. 8 [2-27], p=0.012), total length of hospitalization (6 [1-45] vs. 9 [2-27]; p=0.010), and the rate of emergency readmissions (3.5% vs. 12.2%; p=0.027) were significantly higher in the LCBDE failure group.

CONCLUSIONS

Upfront LCBDE for CBDS was associated with improved outcomes compared to intra-/postoperative ERCP recourse. Male sex, pediculitis, thin CBD, and surgery later than 4 p.m were associated with LCBDE failure and the need for endoscopic treatment.

REGISTRATION NUMBER AND AGENCY

The present retrospective study was approved by our local ethics committee and was declared on ClinicalTrials.gov (ID: NCT04467710).

Comprehensive review on small common bile duct stones

Common bile duct stones are among the most common conditions encountered by endoscopists. Therefore, it is well researched; however, some items, such as indications for endoscopic papillary balloon dilatation (EPBD), safety of EPBD and endoscopic sphincterotomy in patients receiving dual antiplatelet therapy or direct oral anticoagulant, selection strategy for retrieval balloons and baskets, lack adequate evidence. Therefore, the guidelines have been updated with new research, while others remain unchanged due to weak evidence. In this review, we comprehensively summarize the standard methods in guidelines and new findings from recent studies on papillary dilation, stone retrieval devices, difficult-to-treat cases, troubleshooting during the procedure, and complicated cases of cholangitis, cholecystolithiasis, or distal biliary stricture.

The clinical effect of primary duct closure and T-tube drainage: A propensity score matched study

BACKGROUND

Although laparoscopic common bile duct exploration (LCBDE) is considered a safe and effective method for the removal of bile duct stones, selecting primary duct closure (PDC) or T-tube drainage (TTD) following choledochotomy remains controversial. This study aims to explore the clinical effects of PDC and TTD after LCBDE.

METHODS

We retrospectively analyzed clinical data of 348 patients with choledocholithiasis treated with LCBDE from January 2016 to October 2020. All patients were divided into PDC (225 cases) and TTD (123 cases) groups. Propensity score matching (PSM) was performed. We compared operative parameters and outcomes.

RESULTS

After matching (n = 116/group), no significant difference was observed between the two groups (P > 0.05) regarding intra-abdominal infection, incision infection, bile leakage, and retained stones. In terms of operation time, intraoperative blood loss, postoperative hospital stay, postoperative exhaust time, postoperative antibiotic use time, and postoperative abdominal drainage time, PDC group was obviously superior to TTD group (P < 0.05).

CONCLUSION

Primary closure following LCBDE is considered a safe and effective alternative to T-tube drainage.

Management of cholelithiasis with choledocholithiasis: Endoscopic and surgical approaches

Gallstone disease and complications from gallstones are a common clinical problem. The clinical presentation ranges between being asymptomatic and recurrent attacks of biliary pain requiring elective or emergency treatment. Bile duct stones are a frequent condition associated with cholelithiasis. Amidst the total cholecystectomies performed every year for cholelithiasis, the presence of bile duct stones is 5%-15%; another small percentage of these will develop common bile duct stones after intervention. To avoid serious complications that can occur in choledocholithiasis, these stones should be removed. Unfortunately, there is no consensus on the ideal management strategy to perform such. For a long time, a direct open surgical approach to the bile duct was the only unique approach. With the advent of advanced endoscopic, radiologic, and minimally invasive surgical techniques, however, therapeutic choices have increased in number, and the management of this pathological situation has become multidisciplinary. To date, there is agreement on preoperative management and the need to treat cholelithiasis with choledocholithiasis, but a debate still exists on how to cure the two diseases at the same time. In the era of laparoscopy and mini-invasiveness, we can say that therapeutic approaches can be performed in two sessions or in one session. Comparison of these two approaches showed equivalent success rates, postoperative morbidity, stone clearance, mortality, conversion to other procedures, total surgery time, and failure rate, but the one-session treatment is characterized by a shorter hospital stay, and more cost benefits. The aim of this review article is to provide the reader with a general summary of gallbladder stone disease in association with the presence of common bile duct stones by discussing their epidemiology, clinical and diagnostic aspects, and possible treatments and their advantages and limitations.

Reinterventions following laparoscopic cholecystectomy and bile duct exploration. A review of prospective data from 5740 patients

Background

Complications following laparoscopic cholecystectomy (LC) and common bile duct exploration (CBDE) for the management of gallstones or choledocholithiasis impact negatively on patients’ quality of life and may lead to reinterventions. This study aims to evaluate the causes and types of reintervention following index admission LC with or without CBDE.

Methods

A prospectively maintained database of LC and CBDE performed by a single surgeon was analysed. Preoperative factors, difficulty grading and perioperative complications requiring reintervention and readmissions were examined.

Results

Reinterventions were required in 112 of 5740 patients (2.0%), 89 (1.6%) being subsequent to complications. The reintervention cohort had a median age of 64 years, were more likely to be females (p < 0.0023) and to be emergency admissions (67.9%, p < 0.00001) with obstructive jaundice (35.7%, p < 0.00001). 46.4% of the reintervention cohort had a LC operative difficulty grade IV or V and 65.2% underwent a CBDE. Open conversion was predictive of the potential for reintervention (p < 0.00001). The most common single cause of reintervention was retained stones (0.5%) requiring ERCP followed by bile leakage (0.3%) requiring percutaneous drainage, ERCP and relaparoscopy. Relaparoscopy was necessary in 17 patients and open surgery in 13, 6 of whom not resulting from complications. There were 5 deaths.

Conclusion

This large series had a low incidence of reinterventions resulting from complications in spite of a high workload of index admission surgery for biliary emergencies and bile duct stones. Surgical or endoscopic reinterventions following LC alone occurred in only 0.8%. The most common form of reintervention was ERCP for retained CBD stones. This important outcome parameter of laparoscopic biliary surgery can be optimised through early diagnosis and timely reintervention for complications.

Outcomes of laparoscopic bile duct exploration for choledocholithiasis with small common bile duct

BACKGROUND

Laparoscopic cholecystectomy (LC) combined with laparoscopic common bile duct (CBD) exploration (LCBDE) is one of the main treatments for choledocholithiasis with CBD diameter of larger than 10 mm. However, for patients with small CBD (CBD diameter ≤ 8 mm), endoscopic sphincterotomy remains the preferred treatment at present, but it also has some drawbacks associated with a series of complications, such as pancreatitis, hemorrhage, cholangitis, and duodenal perforation. To date, few studies have been reported that support the feasibility and safety of LCBDE for choledocholithiasis with small CBD.

AIM

To investigate the feasibility and safety of LCBDE for choledocholithiasis with small CBD.

METHODS

A total of 257 patients without acute cholangitis who underwent LC + LCBDE for cholecystolithiasis from January 2013 to December 2018 in one institution were reviewed. The clinical data were retrospectively collected and analyzed. According to whether the diameter of CBD was larger than 8 mm, 257 patients were divided into large CBD group (n = 146) and small CBD group (n = 111). Propensity score matching (1:1) was performed to adjust for clinical differences. The demographics, intraoperative data, short-term outcomes, and long-term follow-up outcomes for the patients were recorded and compared.

RESULTS

In total, 257 patients who underwent successful LC + LCBDE were enrolled in the study, 146 had large CBD and 111 had small CBD. The median follow-up period was 39 (14-86) mo. For small CBD patients, the median CBD diameter was 0.6 cm (0.2-2.0 cm), the mean operating time was 107.2 ± 28.3 min, and the postoperative bile leak rate, rate of residual CBD stones (CBDS), CBDS recurrence rate, and CBD stenosis rate were 5.41% (6/111), 3.60% (4/111), 1.80% (2/111), and 0% (0/111), respectively; the mean postoperative hospital stay was 7.4 ± 3.6 d. For large CBD patients, the median common bile duct diameter was 1.0 cm (0.3-3.0 cm), the mean operating time was 115.7 ± 32.0 min, and the postoperative bile leak rate, rate of residual CBDS, CBDS recurrence rate, and CBD stenosis rate were 5.41% (9/146), 1.37% (2/146), 6.85% (10/146), and 0% (0/146), respectively; the mean postoperative hospital stay was 7.7 ± 2.7 d. After propensity score matching, 184 patients remained, and all preoperative covariates except diameter of CBD stones were balanced. Postoperative bile leak occurred in 11 patients overall (5.98%), and no difference was found between the small CBD group (4.35%, 4/92) and the large CBD group (7.61%, 7/92). The incidence of CBDS recurrence did not differ significantly between the small CBD group (2.17%, 2/92) and the large CBD group (6.52%, 6/92).

CONCLUSION

LC + LCBDE is safe and feasible for choledocholithiasis patients with small CBD and did not increase the postoperative bile leak rate compared with chole-docholithiasis patients with large CBD.

Retrospective comparative analysis of choledochoscopic bile duct exploration versus ERCP for bile duct stones

Debate still exists for the management of choledocholithiasis. The purpose of this study is to quantify the rate of recurrent choledocholithiasis post choledochoscopic bile duct exploration (CBDE) in comparison to ERCP and sphincterotomy, and to demonstrate the feasibility of this approach in a busy metropolitan hospital. Data of patients undergoing CBDE from 2009–2014 at the Northern Hospital, Victoria, Australia, was collected retrospectively. Primary outcomes were bile duct clearance rate and rate of recurrent stones post-clearance. Secondary outcomes measured were post-operative complications, laparoscopic to open conversion rate and operative time. Data of patients undergoing ERCP at the same institution was collected and compared. In total, there were 4,091 cholecystectomy cases performed from 2009–2014, of which 260 (6.3%) of patients had an intraoperative cholangiography (IOC) indicating a common bile duct (CBD) stone. Two hundred and forty-eight patients (95.3%) had a CBDE. The remaining 12 patients (4.6%) had radiological clearance, which were excluded from the study. The overall clearance rate for patients undergoing CBDE was 84% (209/248). The risk of recurrent stones up to 8 years post clearance was 2% (4/209). In the same institution, and between 1998–2012, a total of 1,148 patients underwent ERCP, of which 571 had endoscopic sphincterotomy (ES). Forty-three patients required a repeat ERCP for recurrent CBD stones with a complication rate of 7.5%. Time to recurrence ranged from 6 months to 10 years with a mean of 4.5 years. The rate of recurrence was lower in the CBDE group compared to the patients who had an ERCP (8.9% vs. 2%). CBDE is a feasible and effective method for clearance of CBD stones at the time of laparoscopic cholecystectomy. This approach, although not widely used, reduces the need for ERCP, which has inherent complications. In the longer term, this series showed a significant reduction in the rate of CBD stone recurrence.

Laparoscopic transcystic common bile duct exploration (LTCBDE): a safer method to treat common bile duct stones than laparoscopic choledochotomy

We read the article published in the Spanish Journal of Gastroenterology and its accompanying editorial about the laparoscopic treatment of both cholecystolithiasis and choledocholithiasis in a single stage procedure. We would like to make some comments. Common bile duct (CBD) stones can lead to serious complications such as cholangitis and pancreatitis. So far, there is no standard surgical treatment for choledocholithiasis. Although, there are some ways to deal with CBD stones. Each method has its own advantages and disadvantages. In the era of advancements in minimally invasive technology, the treatment of CBD stones still remains controversial with regard to endoscopic retrograde cholangiopancreatography (ERCP) or laparoscopic common bile duct exploration (LCBDE). Preoperative ERCP followed by laparoscopic cholecystectomy (LC) is frequently performed.

Combined gastroscopic and choledochoscopic transabdominal nasobiliary drainage

Common bile duct (CBD) stones are a frequent problem in Chinese populations, and their incidence is particularly high in certain areas (Wang et al., 2013). In recent years, laparoscopic common bile duct exploration (LCBDE) and endoscopic retrograde cholangiopancreatography (ERCP) have been the main surgical procedures for CBD stones, although each has different advantages and disadvantages in the treatment of choledocholithiasis (Loor et al., 2017; Zhou et al., 2017). For patients with large stones, a dilated CBD, especially concurrent gallstones, LCBDE is the preferred and most economical minimally invasive procedure (Koc et al., 2013). However, a T-tube is often placed during LCBDE to prevent postoperative bile leakage; this is associated with problems such as bile loss, electrolyte disturbance, and decreased gastric intake (Martin et al., 1998). In addition, the T-tube usually must remain in place for more than a month, during which time the patient's quality of life is seriously compromised. Many skilled surgeons currently perform primary closure of the CBD following LCBDE, which effectively speeds up rehabilitation (Hua et al., 2015). However, even in sophisticated medical centers, the incidence of postoperative bile leakage still reaches ≥10% (Liu et al., 2017). Especially for a beginner, bile leakage remains a key problem (Kemp Bohan et al., 2017). Therefore, a safe and effective minimally invasive surgical approach to preventing bile leakage during primary closure of the CBD after LCBDE is still urgently needed.

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

Background: To date, several clinical trials have demonstated that both one-stage laparoscopic cholecystectomy (LC) combined with common bile duct exploration (LC+BDE) with primary closure and one-stage LC combined with endoscopic stone extraction (LC+ESE) are the two primary clinical approaches to treat cholelithiasis. However, no studies to date have directly compared the LC+BDE with primary closure and one-stage LC+ESE procedures. We, therefore, conducted a retrospective analysis of patients with cholelithiasis who had been treated through LC+ESE or LC+BDE to compare these two approaches for the treatment of cholecystitis and common bile duct stones (CCBDS). Methods: Consecutive CCBDS patients with cholelithiasis in our hospital who were diagnosed through Media Resource Control Protocol (MRCP) and ultrasound between June 2010 and February 2017 were randomly assigned to undergo either LC+ESE or LC+BDE, as both procedures are routinely used to treat cholelithiasis in our hospital. All patients were made aware of the risks and benefits of the surgery preoperatively, and this study was approved by the ethics committee of our institute. Outcomes in these two groups, including rates of success and reasons for operative failure, were then compared, as were data pertaining to patient demographics, clinical findings, postoperative stay duration, and medical expenses. In addition, biliary reflux as measured through computed tomography or gastrointestinal imaging was monitored for a minimum of 2 years. Results: In total, 207 CCBDS patients were identified during the study period and were randomized into the LC+ESE (n = 103) or LC+BDE (n = 104) treatment groups. We found that patients treated through LC+BDE achieved a significantly higher success rate than that achieved in patients treated through LC+ESE (93.3% versus 82.5%; P < .05). Specifically, the LC+BDE with primary closure procedure failed in patients with impacted stones located at the end of the common bile duct (CBD) and in those with stenosis of the sphincter of Oddi. The only variable that differed significantly between these two treatment groups was stone location. Variables other than stone location, CBD size, and stone size did not differ significantly between the two groups. However, the LC+BDE treatment was associated with significant reductions in patient operating time, morbidity, hospital day duration, and biliary reflux of duodenal contents relative to the LC+ESE treatment. Conclusions: We found that LC+BDE with primary closure was a safer and more effective means of treated CCBDS patients than was the LC+ESE procedure and that it was not associated with risks of sphincterotomy of duodenal papilla (EST)- or T-tube-related complications. However, our data also clearly indicate that LC+BDE cannot replace LC+ESE in all patients, and that as such both approaches should be considered as being complementary to one another, with their relative advantages in a given patient being defined based upon local resource availability and expertise. In addition, when the LC+ESE procedure fails then the LC+BDE treatment can be safely employed as a salvage approach.

Laparoscopic Transcystic Versus Transductal Common Bile Duct Exploration: A Systematic Review and Meta-analysis

OBJECTIVE

To evaluate comparative outcomes of laparoscopic transcystic (TC) and transductal (TD) common bile duct (CBD) exploration.

METHODS

We systematically searched MEDLINE, EMBASE, CINAHL, CENTRAL, the World Health Organization International Clinical Trials Registry, ClinicalTrials.gov, ISRCTN Register, and bibliographic reference lists. CBD clearance rate, perioperative complications, and biliary complications were defined as the primary outcome parameters. Procedure time, length of hospital stay, conversion to open procedure were the secondary outcomes. Combined overall effect sizes were calculated using random-effects models.

RESULTS

We identified 30 studies reporting a total of 4073 patients comparing outcomes of laparoscopic TC (n = 2176) and TD (N = 1897) CBD exploration. The TC approach was associated with significantly lower overall complications (RD: -0.07, P = 0.001), biliary complications (RD: -0.05, P = 0.0003), and blood loss (MD: -16.20, P = 0.02) compared to TD approach. Moreover, the TC approach significantly reduced the length of hospital stay (MD: -2.62, P < 0.00001) and procedure time (MD: -12.73, P = 0.005). However, there was no significant difference in rate of CBD clearance (RD: 0.00, P = 0.77) and conversion to open procedure (RD: 0.00, P = 0.86) between two groups.

CONCLUSIONS

Laparoscopic TC CBD exploration is safe and reduces overall morbidity and biliary complications compared to the TD approach. Moreover, it is associated with significantly shorter length of hospital stay and procedure time. High-quality randomised trials may provide stronger evidence with respect to impact of the cystic duct/CBD diameter, number or size of CBD stones, or cystic duct anatomy on the comparative outcomes of TC and TD approaches.

Meta-analysis of laparoscopic transcystic versus transcholedochal common bile duct exploration for choledocholithiasis

Background

It is not clear whether laparoscopic transcystic exploration (LTCE) laparoscopic choledochotomy (LCD) is superior in the management of choledocholithiasis. In this meta-analysis, the success of LTCE versus LCD was evaluated.

Methods

Cochrane Central Register of Controlled Trials, Web of Science, Trip, PubMed, Ovid and Embase databases were searched systematically for relevant literature up to May 2017. Studies that compared the success rate of LTCE and LCD in patients with choledocholithiasis were included. PRISMA guidelines were followed. Multiple independent reviewers contributed on a cloud-based platform. Random-effects model was used to calculate odds ratios (ORs) or standardized mean differences (MDs) with 95 per cent confidence intervals. An a priori hypothesis was generated based on clinical experience that LTCE is as successful as LCD.

Results

Of 3533 screened articles, 25 studies comprising 4224 patients were included. LTCE achieved a lower duct clearance rate than LCD (OR 0.38, 95 per cent c.i. 0·24 to 0·59). It was associated with a shorter duration of surgery (MD -0·86, 95 per cent c.i. -0·97 to -0·77), lower bile leak (OR 0·46, 0·23 to 0·93) and shorter hospital stay (MD -0·78, -1·14 to -0·42) than LCD. There was no statistically significant difference in conversion, stricture formation or reintervention rate.

Conclusion

LCD has a higher rate of successful duct clearance, but is associated with a longer duration of surgery and hospital stay, and a higher bile leak rate.

T-Tube Use After Laparoscopic Common Bile Duct Exploration

Background and Objectives:

Laparoscopic common bile duct exploration (LCBDE) has been verified to be an effective technique in treating choledocholithiasis, and T-tube insertion has been widely performed after LCBDE. With growing doubts regarding the effectiveness and safety of T-tube drainage (TTD), it has been suggested to replace such with primary duct closure (PDC). This meta-analysis aimed to evaluate the short- and long-term effectiveness and safety of PDC compared with TTD after LCBDE.

Methods:

The PubMed, Science Citation Index, and Cochrane Central Register of Controlled Trials databases were used to accomplish a systematic literature search for randomized controlled trials and pro-/retrospective cohort studies that compared PDC alone or PDC combined with biliary drainage stenting (PDC+BD) with TTD after LCBDE. A subgroup analysis was established to compare PDC+BD with TTD. RevMan 5.3 was used for the statistical analysis.

Results:

A total of 2552 patients from 26 studies were included. The pooled odds ratio supported PDC, which yielded lower postoperative overall morbidity and incidence of bile leak and bile peritonitis and shorter surgical time and postoperative hospital stay when compared with TTD. In the subgroup analysis, PDC+BD showed significantly better results in terms of postoperative overall morbidity, incidence of bile leak and bile peritonitis, surgical time, and postoperative hospital stay than did TTD. PDC and PDC+BD showed no difference in the incidence of recurrent stones and biliary stricture during the long-term follow-up period compared with TTD.

Conclusion:

PDC alone or PDC+BD is superior to TTD as a duct-closure method after LCBDE.

Technical Aspects of Bile Duct Evaluation and Exploration: An Update

Consensus guidelines recommend patients with symptomatic cholelithiasis and suspected choledocholithiasis have common bile duct exploration (CBDE) at the time of cholecystectomy to prevent downstream problems. Despite superiority of single-stage cholecystectomy with CBDE, 2-stage precholecystectomy/postcholecystectomy with endoscopic clearance of the duct is commonly practiced. This is related to inadequate training in minimally invasive techniques, lack of technical support for efficient and safe CBDE, and surgeons' inexperience with complex biliary pathologic condition. This article provides a framework for evaluating and treating patients with CBD pathologic condition with an emphasis on technical aspects of CBDE and preoperative planning and preparation.

Should T-Tube Drainage be Performed for Choledocholithiasis after Laparoscopic Common Bile Duct Exploration? A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) has been verified to be a comparatively effective treatment approach for uncomplicated choledocholithiasis, and it has been previously proposed that the primary duct closure (PDC) technique, in which the bile duct can directly be sutured in only 1 step compared with the T-tube drainage (TTD), can be deemed a choice after LCBDE; however, the conventional TTD performance is controversial in the minimally invasive surgery era. On the basis of the above-mentioned point, this meta-analysis was conducted to assess the different effects between TTD and PDC after LCBDE.

MATERIALS AND METHODS

In PubMed, EMBASE, and the Cochrane Library, literature search was conducted to screen out randomized controlled trials (RCTs) to compare PDC with TTD. The analyzed outcome variables included overall morbidity, biliary-specific morbidity (retained stones, biliary leak, biliary peritonitis), other morbidities, operating time, postoperative hospital stay, reintervention (surgery, endoscopy/radiology), and median hospital expenses.

RESULTS

In this meta-analysis, there are 4 RCTs qualifying for inclusion, including 396 patients in all (222 in PDC and 214 in TTD). With respect to postoperative overall morbidity (P<0.05), biliary peritonitis (P<0.05), surgery time (P<0.05), length of stay (P<0.05), and median hospital expenses (P<0.05), PDC presented remarkably better results than TTD (P<0.05). Statistically, no remarkable distinction was found between the 2 groups as to biliary-specific morbidity, retained stones, biliary leak, other morbidities, or reintervention (radiology/endoscopy, surgery).

CONCLUSIONS

In this meta-analysis, there was no evidence provided for clinical benefits of using TTD after LCBDE. Therefore, TTD should not routinely be performed after LCBDE. However, multicenter, large sample size, RCTs should be conducted to clarify this issue.

Various approaches of laparoscopic common bile duct exploration plus primary duct closure for choledocholithiasis: A systematic review and meta-analysis

BACKGROUND

Common bile duct (CBD) stones may occur in up to 3%-14.7% of all patients with cholecystectomy. Various approaches of laparoscopic CBD exploration plus primary duct closure (PDC) are the most commonly used and the best methods to treat CBD stone. This systematic review was to compare the effectiveness and safety of the various approaches of laparoscopic CBD exploration plus PDC for choledocholithiasis.

DATA SOURCES

Randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) (case-control studies or cohort studies) were searched from Cochrane library (until Issue 2, 2015), Web of Science (1980-January 2016), PubMed (1966-January 2016), and Baidu search engine. After independent quality assessment and data extraction, meta-analysis was conducted using RevMan 5.1 software.

RESULTS

Four RCTs and 18 NRCTs were included. When compared with choledochotomy exploration (CE) plus T-tube drainage (TTD) (CE + TTD), CE plus PDC (CE + PDC) and CE + PDC with biliary drainage (BD) (CE + PDC + BD) had a lower rate of postoperative biliary peritonitis (OR = 0.22; 95% CI: 0.06, 0.88; P < 0.05; OR = 0.27; 95% CI: 0.08, 0.84; P < 0.05; respectively) where T-tubes were removed more than 3 weeks. The operative time of CE + PDC was significantly shorter (WMD = -24.82; 95% CI: -27.48, -22.16; P < 0.01) than that of CE + TTD in RCTs. Cystic duct exploration (CDE) plus PDC (CDE + PDC) has a lower rate of postoperative complications (OR = 0.39; 95% CI: 0.23, 0.67; P < 0.01) when compared with CE + PDC. Confluence part micro-incision exploration (CME) plus PDC (CME + PDC) has a lower rate of postoperative bile leakage (OR = 0.17; 95% CI: 0.04, 0.74; P < 0.05) when compared with CE + PDC.

CONCLUSION

PDC with other various approaches are better than TTD in the treatment of choledocholithiasis.

Laparoscopic common bile duct exploration versus endoscopic retrograde cholangiopancreatography for choledocholithiasis found at time of laparoscopic cholecystectomy: Analysis of a large integrated health care system database

BACKGROUND

We compared endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic common bile duct exploration (LCBDE) for managing choledocholithiasis found at time of cholecystectomy.

METHODS

One hundred and five LCBDE (2005-2015) were compared to 195 LC/ERCP (2014-2015) from the Southern California Kaiser Permanente database.

RESULTS

LC/ERCP was more effective at clearing the CBD (98% vs. 88.6%, p = 0.01); but required more procedures per patient (mean ± standard deviation, 1.1 ± 0.4 vs. 2.0 ± 0.12, p < 0.001). Morbidity, hospital length of stay and readmission were not different (P > 0.05). Four patients failed ERCP, while 12 patients failed LCBDE and had subsequent ERCP (10) or CBD exploration (2). All patients with RYGB had successful LCBDE.

CONCLUSION

LC/ERCP is better than LCBDE in clearing CBD stones, but has similar morbidity and is an effective alternative for patients with RYGB.

Percutaneous transhepatic papilla balloon dilatation combined with a percutaneous transcystic approach for removing concurrent gallbladder stone and common bile duct stone in a patient with billroth II gastrectomy and acute cholecystitis: A case report

BACKGROUND

A 61-year-old man presented with upper abdominal pain and jaundice. Abdominal computed tomography imaging revealed stones in the gallbladder and the common bile duct, with a thickening of the gallbladder wall and an obvious increase in the volume of the gallbladder. Initial treatment using endoscopic retrograde cholangiopancreatography failed due to the presence of surgically altered gastrointestinal anatomy. Stones in the gallbladder and common bile duct were subsequently removed concurrently via percutaneous transhepatic papilla balloon dilatation combined with a percutaneous transcystic approach. Liver function recovered rapidly, with total bilirubin and direct bilirubin levels decreasing to normal, with a concomitant improvement in hemoglobin and thrombocyte levels and resolution of the upper abdominal pain and jaundice.

CONCLUSION

Percutaneous transhepatic papilla balloon dilatation, combined with a percutaneous transcystic approach, provided an effective alternative treatment for removing concurrent stones in the common bile duct and gallbladder in a patient with a previous Billroth II gastrectomy and presenting with an acute cholecystitis.

Safety and efficacy of a novel continuous incision technique for laparoscopic transcystic choledocholithotomy

INTRODUCTION

The purpose of this study was to evaluate the safety and efficacy of a novel continuous incision technique for the cystic duct and the bile duct over the orifice for laparoscopic transcystic choledocholithotomy (LTCL).

METHODS

LTCL was attempted in 103 consecutive patients from January 1998 to March 2015 and was successful in 96 patients. The cystic duct confluence was made by cutting upward from the orifice in 19 patients. The cystic duct was incised downward beyond the orifice to the bile duct in the other 77 patients. Both of these procedures involved LTCL.

RESULTS

LTCL was successful in 96 patients. It failed in seven patients because of large bile duct stones (BDS), left lateral entry of the cystic duct, or the cystic duct's small diameter. The success rates of LTCL were 98% (47/48), 96% (42/44), and 64% (7/11) for patients with BDS <10 mm, 10-20 mm, and ≥20 mm, respectively. The success rate for removing BDS <20 mm was significantly higher than the removal rate for BDS ≥20 mm (P < 0.0001). There was no significant difference between the incidences of complications associated with BDS ≥10 mm and with BDS <10 mm (P = 0.49). In those who underwent successful LTCL, complications occurred in 3 of 23 patients with failed preoperative duodenoscopic sphincterotomy and in 9 of the other 73 patients; the incidence of complications did not significantly differ between these groups (P = 0.93).

CONCLUSION

LTCL is safe and feasible for exploration of the bile duct and removal of BDS <20 mm.

Evidence-based clinical practice guidelines for cholelithiasis 2016

Cholelithiasis is one of the commonest diseases in gastroenterology. Remarkable improvements in therapeutic modalities for cholelithiasis and its complications are evident. The Japanese Society of Gastroenterology has revised the evidence-based clinical practice guidelines for cholelithiasis. Forty-three clinical questions, for four categories-epidemiology and pathogenesis, diagnosis, treatments, and prognosis and complications-were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases for the period between 1983 and June 2012. The guidelines were developed with use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. This article preferentially describes the clinical management of cholelithiasis and its complications. Following description of the diagnosis performed stepwise through imaging modalities, treatments of cholecystolithiasis, choledocholithiasis, and hepatolithiasis are introduced along with a flowchart. Since there have been remarkable improvements in endoscopic treatments and surgical techniques, the guidelines ensure flexibility in choices according to the actual clinical environment. The revised clinical practice guidelines are appropriate for use by clinicians in their daily practice.

Advances of recurrent risk factors and management of choledocholithiasis

Gallstone disease is a common and frequently occurring disease in human, and it is the main disease among the digestive system diseases. The incidence of gallstone disease in western countries is about 5%-22%, and common bile duct stones (CBDS) accounts for 8%-20%. CBDS easily lead to biliary obstruction, secondary cholangitis, pancreatitis, and obstructive jaundice, even endanger life. Therefore, it needs timely treatment once diagnosed. The recurrence of choledocholithiasis after bile duct stones clearance involves complicated factors and cannot be completely elaborated by a single factor. The risk factors for recurrence of choledocholithiasis include bacteria, biliary structure, endoscopic and surgical treatment, and inflammation. The modalities for management of choledocholithiasis are endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic or open common bile duct exploration, dissolving solutions, extracorporeal shockwave lithotripsy (ESWL), percutaneous radiological interventions, electrohydraulic lithotripsy (EHL) and laser lithotripsy. We compare the different benefits between surgery and ERCP. And finally, we make a summary of the current strategy for reducing the recurrence of CBDS and future perspectives for CBDS management.

Primary Closure Versus Biliary Drainage After Laparoscopic Choledocotomy: Results of a Comparative Study

INTRODUCTION

To evaluate the feasibility, safety, and short-term outcomes of primary closure (PC) and biliary drainage (BD), after the laparoscopic treatment of common bile duct (CBD) stones by choledocotomy.

PATIENTS AND METHODS

Between January 2009 and December 2014, 102 patients underwent laparoscopy for lithiasis of the CBD. Intraoperative cholangiography was systematically performed, followed by choledocoscopy, depending on the size of the CBD.

RESULTS

Eighty (78.4%) of the 102 patients underwent laparoscopic stone extraction by choledocotomy, and were assigned to 2 groups: PC (group A, n=25), and BD (group B, n=55). Groups A and B were comparable in terms of age (62.3±26.1 vs. 66.0±19.3 y; P=0.53), the percentage of women (72.0% vs. 76.4%; P=0.68), body mass index (25.9±6.1 vs. 26.9±4.4 kg/m; P=0.52), and CBD diameter (11.6±3.1 vs. 12.1±3.8 mm; P=0.59). The mean durations of surgery and of hospital stay were significantly shorter in group A: 179±38 versus 211±57 minutes (P=0.02) and 5.4±2.0 versus 8.4±3.2 days (P<0.001). Groups A and B were comparable in terms of serious postoperative morbidity (Clavien-Dindo scores of 3, 4, and 5): 2 versus 4 (P=1). In group B, bile drain removal was complicated by choleperitoneum in 3 cases.

CONCLUSIONS

With shorter durations of surgery and hospital stay, equivalent postoperative morbi-mortality, and an absence of the specific morbidity due to bile drainage, PC may be considered a safe and feasible option for the laparoscopic management of CBD stones by choledocotomy.

Laparoscopic Transcystic Common Bile Duct Exploration: Advantages over Laparoscopic Choledochotomy

Purpose

The ideal treatment for choledocholithiasis should be simple, readily available, reliable, minimally invasive and cost-effective for patients. We performed this study to compare the benefits and drawbacks of different laparoscopic approaches (transcystic and choledochotomy) for removal of common bile duct stones.

Methods

A systematic search was implemented for relevant literature using Cochrane, PubMed, Ovid Medline, EMBASE and Wanfang databases. Both the fixed-effects and random-effects models were used to calculate the odds ratio (OR) or the mean difference (MD) with 95% confidence interval (CI) for this study.

Results

The meta-analysis included 18 trials involving 2,782 patients. There were no statistically significant differences between laparoscopic choledochotomy for common bile duct exploration (LCCBDE) (n = 1,222) and laparoscopic transcystic common bile duct exploration (LTCBDE) (n = 1,560) regarding stone clearance (OR 0.73, 95% CI 0.50–1.07; P = 0.11), conversion to other procedures (OR 0.62, 95% CI 0.21–1.79; P = 0.38), total morbidity (OR 1.65, 95% CI 0.92–2.96; P = 0.09), operative time (MD 12.34, 95% CI −0.10–24.78; P = 0.05), and blood loss (MD 1.95, 95% CI −9.56–13.46; P = 0.74). However, the LTCBDE group showed significantly better results for biliary morbidity (OR 4.25, 95% CI 2.30–7.85; P<0.001), hospital stay (MD 2.52, 95% CI 1.29–3.75; P<0.001), and hospital expenses (MD 0.30, 95% CI 0.23–0.37; P<0.001) than the LCCBDE group.

Conclusions

LTCBDE is safer than LCCBDE, and is the ideal treatment for common bile duct stones.

Long-term Outcome of Primary Closure After Laparoscopic Common Bile Duct Exploration Combined With Choledochoscopy

BACKGROUND

Primary closure after laparoscopic common bile duct exploration (LCBDE) is considered to be a safe alternative to T-tube drainage on the basis of the short-term outcome. However, little published data exist regarding the biliary complications at the long-term follow-up of primary closure versus T-tube drainage following LCBDE. Hence, the aim of this study is to assess the long-term outcome of primary closure after LCBDE.

MATERIALS AND METHODS

This is a retrospective study of 142 consecutive patients who underwent LCBDE combined with choledochoscopy for CBD stones. After LCBDE, the choledochotomy was closed by primary closure (group P) in 91 patients (64.1%) and with T-tube drainage (group T) in 51 patients (35.9%). The data on operative outcome and long-term biliary complications were compared between the 2 groups.

RESULTS

The mean operation time was significantly shorter in group P than group T (168.9 ± 50.1 min for group P vs. 198.0 ± 59.6 min for group T, P = 0.002). The hospital stay was significantly shorter in group P than in group T (8.59 ± 6.0 d for group P vs. 14.96 ± 5.4 d for group T, P = 0.001). Postoperative bile leak occurred in 2 patients (2.2%) in group P and 1 patient (2.0%) in group T. With a mean follow-up of 48.8 months, the stone recurrence rate in group P and group T were 4.4% and 5.9%, respectively (P = 0.722). During the follow-up period, there was no sign of biliary stricture or other biliary complications in both groups.

CONCLUSIONS

The long-term follow-up data on primary closure after LCBDE indicated a low incidence of recurrent stones, and no biliary strictures. Thus, primary closure after LCBDE with choledochoscopy is considered to be a safe and effective alternative to T-tube drainage in terms of long-term outcome.

Knotless choledochorraphy with barbed suture, safe and feasible

PURPOSE

To describe the safety and feasibility of a running continuous unidirectional barbed suture (V-Loc, Covidien, Mansfield, MA) for primary common bile duct closure while performing laparoscopic common bile duct exploration (LCBDE).

INTRODUCTION

LCBDE is nowadays the best approach for treating complex common bile duct lithiasis or cases where the endoscopic retrograde cholangiopancreatography has failed. It is clear that the primary closure of the common bile duct must be preferred over the T-tube drainage. The actual technical aspects offer room for improvement. We present our experience with barbed suture, for which recently, various fields of surgery have become interested in and which now has a series of studies that support it for several uses.

METHODS

Between July 2012 and July 2014, 54 consecutive patients with bile duct stones underwent LCBDE by a single surgeon. Perioperative outcomes and 30-day complications were recorded.

RESULTS

Upon the completion of the exploration, 50 patients had primary common bile duct closure using knotless unidirectional barbed 3-0 V-Loc 90 suture, and 4 patients were excluded. All of the sutures were performed without knot tying. The procedure in all patients was successfully performed with no intraoperative complications. There were no bile leaks in the 50 patients or other postoperative complications such as infection, need for reintervention or death.

CONCLUSION

The use of unidirectional knotless barbed suture (V-Loc 90) is safe, feasible and effective on LCBDE for primary common bile duct closure. The biliary leak rate is acceptably low and comparable to the rate reported in the literature. This report is our initial experience that needs further clinical trials.

Usefulness of early post-operative liver function test monitoring after laparoscopic common bile duct exploration

BACKGROUND

This study examines the usefulness of early post-operative liver function test (LFT) monitoring in predicting retained choledocholithiasis after laparoscopic common bile duct exploration (LCBDE).

METHODS

Data on patients who had LCBDE over a 3-year period were collected retrospectively. Patients who had ongoing choledocholithiasis after unsuccessful LCBDE were considered for the test group and patients who had successful LCBDE were considered for the control group. Preoperative, day 1 post-operative and day 2 post-operative alkaline phosphatase (ALP), gamma glutamyl transferase (GGT), alanine transaminase (ALT) and bilirubin levels were recorded. Proportions of patients who had worsening LFTs were analysed in each group.

RESULTS

Proportions of patient who had worsening LFTs on day 1 were not statistically different between two groups and they were statistically equal on equivalence testing (two one-sided tests). On day 2, proportions of patient were again not statistically different. Bilirubin and ALT were statistically equivalent (P = 0.022 and P = 0.025 respectively) but GGT and ALP failed to achieve statistical equivalence (P = 0.062 and P = 0.138 respectively) on day 2. Twelve patients with normal appearing final intraoperative cholangiogram needed reintervention due to retained choledocholithiasis diagnosed subsequently. LFTs progressively improved despite presence of choledocholithiasis in eight of these 12 patients (75%) and only four were diagnosed by worsening post-operative LFTs during index admission.

CONCLUSION

LFTs in the early post-operative period are not useful in determining which patients require biliary imaging or intervention after an apparently successful LCBDE.

Systematic review with meta-analysis of studies comparing primary duct closure and T-tube drainage after laparoscopic common bile duct exploration for choledocholithiasis

BACKGROUND

With advances in laparoscopic instrumentation and acquisition of advanced laparoscopic skills, laparoscopic common bile duct exploration (LCBDE) is technically feasible and increasingly practiced by surgeons worldwide. Traditional practice of suturing the dochotomy with T-tube drainage may be associated with T-tube-related complications. Primary duct closure (PDC) without a T-tube has been proposed as an alternative to T-tube placement (TTD) after LCBDE. The aim of this meta-analysis was to evaluate the safety and effectiveness of PDC when compared to TTD after LCBDE for choledocholithiasis.

METHODS

A systematic literature search was performed using PubMed, EMBASE, MEDLINE, Google Scholar, and the Cochrane Central Register of Controlled Trials databases for studies comparing primary duct closure and T-tube drainage. Studies were reviewed for the primary outcome measures: overall postoperative complications, postoperative biliary-specific complications, re-interventions, and postoperative hospital stay. Secondary outcomes assessed were: operating time, median hospital expenses, and general complications.

RESULTS

Sixteen studies comparing PDC and TTD qualified for inclusion in our meta-analysis, with a total of 1770 patients. PDC showed significantly better results when compared to TTD in terms of postoperative biliary peritonitis (OR 0.22, 95% CI 0.06-0.76, P = 0.02), operating time (WMD, -22.27, 95% CI -33.26 to -11.28, P < 0.00001), postoperative hospital stay (WMD, -3.22; 95% CI -4.52 to -1.92, P < 0.00001), and median hospital expenses (SMD, -1.37, 95% CI -1.96 to -0.77, P < 0.00001). Postoperative hospital stay was significantly decreased in the primary duct closure with internal biliary drainage (PDC + BD) group when compared to TTD group (WMD, -2.68; 95% CI -3.23 to -2.13, P < 0.00001).

CONCLUSIONS

This comprehensive meta-analysis demonstrates that PDC after LCBDE is feasible and associated with fewer complications than TTD. Based on these results, primary duct closure may be considered as the optimal procedure for dochotomy closure after LCBDE.

Primary closure and rate of bile leak following laparoscopic common bile duct exploration via choledochotomy

BACKGROUND

Choledocholithiasis is traditionally managed by endoscopic retrograde cholangiopancreatography or T-tube insertion following common bile duct exploration. This study examined the efficacy and safety of primary duct closure following laparoscopic common bile duct exploration (LCBDE) via choledochotomy.

METHODS

Between September 2011 and September 2013, 157 consecutive patients underwent LCBDE via choledochotomy.

RESULTS

Of 157 LCBDE procedures, 138 (87.9%) were successfully completed with primary closure of the choledochotomy. Eight patients (5.1%) underwent closure with T-tube drainage after choledochotomy and 11 patients (7.0%) were converted to open surgery. The biliary tree was free of stones at the end of surgery in 154 patients (98.1%). Postoperative bile leak occurred in 6 patients (3.8%). The median follow-up period was 18 (2-33) months, with no evidence of further bile duct stones or bile duct stricture in any patients. Univariable analysis revealed that successful duct clearance (p = 0.010) and diameter of the common bile duct (p < 0.001) were two significant risk factors for bile leak.

CONCLUSIONS

Primary duct closure following LCBDE is effective and safe for the management of choledocholithiasis. The postoperative bile leak rate may be low in skilled laparoscopic surgeons with a careful selection of patients.

Single-session minimally invasive management of common bile duct stones

Up to 18% of patients submitted to cholecystectomy had concomitant common bile duct stones. To avoid serious complications, these stones should be removed. There is no consensus about the ideal management strategy for such patients. Traditionally, open surgery was offered but with the advent of endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) minimally invasive approach had nearly replaced laparotomy because of its well-known advantages. Minimally invasive approach could be done in either two-session (preoperative ERCP followed by LC or LC followed by postoperative ERCP) or single-session (laparoscopic common bile duct exploration or LC with intraoperative ERCP). Most recent studies have found that both options are equivalent regarding safety and efficacy but the single-session approach is associated with shorter hospital stay, fewer procedures per patient, and less cost. Consequently, single-session option should be offered to patients with cholecysto-choledocholithiaisis provided that local resources and expertise do exist. However, the management strategy should be tailored according to many variables, such as available resources, experience, patient characteristics, clinical presentations, and surgical pathology.

Surgery for common bile duct stones--a lost surgical skill; still worthwhile in the minimally invasive century?

PURPOSE

Techniques of laparoscopic bile duct exploration have been reported for over 20 years. Despite the simplicity and success of these procedures, they have failed to become commonplace in most surgical departments, as endoscopic retrograde cholangiopancreatography (ERCP) has become the preferred method for dealing with bile duct stones. There is a risk of surgeons not obtaining or losing these skills, which may still be required as a definitive treatment when ERCP fails or is not available.

METHODS AND RESULTS

This paper describes these laparoscopic operations, which can be performed to enable a 'one-stop shop' treatment of common bile duct stones (CBDS) at the time of cholecystectomy. In particular, transcystic basket clearance of the bile duct is possible in two-thirds of cases with very little increase in morbidity compared to routine cholecystectomy. The selection of patients who are most likely to be successfully treated with this technique is defined. Some of the authors have published large study series and prospective randomised trials, further refining the choices available to the surgeon who, when performing operative cholangiography, is already halfway to bile duct exploration.

CONCLUSIONS

Surgery may reclaim this lost ground by offering an excellent and safe therapeutic option for many of the symptomatic CBDS.

Use of biliary stent in laparoscopic common bile duct exploration

INTRODUCTION

It is well supported in the literature that laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis has equal efficacy when compared to ERCP followed by laparoscopic cholecystectomy. Decompression after supra-duodenal choledochotomy is common practice as it reduced the risk of bile leaks. We conducted a prospective non-randomized study to compare outcomes and length of stay in patients undergoing biliary stent insertion versus T-tube drainage following LCBDE via choledochotomy.

METHODS AND PROCEDURES

The study involved 116 patients with choledocholithiasis who underwent LCBDE and decompression of the biliary system by either ante-grade biliary stent or T-tube insertion. A 7 French straight/duodenal curve biliary Diagmed™ stent (9-11 cm) was placed in 82 patients (Biliary Stent Group). T-tube insertion was used for 34 patients (T-tube group). The length of hospital stay and complications for the selected patients were recorded. All trans-cystic common bile duct explorations were excluded from the study.

RESULTS

The mean hospital stay for patients who underwent ante-grade biliary stent or T-tube insertion after LBCDE were 1 and 3.4 days, respectively. This is a statistically significant result with a p value of less than 0.001. Of the T-tube group, two patients required laparoscopic washout due to bile leaks, one had ongoing biliary stasis and one reported ongoing pain whilst the T-tube was in situ. A complication rate of 11.2%, this was a significant finding. There were no complications or concerns reported for the Biliary Stent Group.

CONCLUSION

Our results show that there is a significant reduction in length of hospital stay and morbidity for patients that have ante-grade biliary stent decompression of the CBD post laparoscopic choledochotomy when compared T-tube drainage. This implies that ante-grade biliary stent insertion is likely to reduce costs and increase overall patient satisfaction. We support the use of ante-grade biliary stent insertion during LCBDE when primary closure is not preferred.

Systematic review and meta-analysis of minimally invasive techniques for the management of cholecysto-choledocholithiasis

BACKGROUND

The optimal management of patients with symptomatic gallstones and possible or proven common bile duct (CBD) stones and gallstones is still evolving. Today a number of options exist: preoperative endoscopic retrograde cholangiopancreatography (pre-op ERCP), laparoscopic cholecystectomy (LC) combined with intraoperative endoscopic sphincterotomy (IOES), laparoscopic common bile duct exploration (LCBDE) and postoperative ERCP (post-op ERCP). This meta-analysis was done to compare these management options and determine if any single option was clearly superior.

METHODS

A systematic search was conducted using several electronic databases. The search revealed 15 randomized controlled trials (RCTs). Six comparing pre-op ERCP with LCBDE, five comparing pre-op ERCP with IOES, two comparing IOES with LCBDE and two comparing post-op ERCP with LCBDE, comprising a total of 1992 patients.

RESULTS

The pre-op ERCP group had a significantly higher incidence of ERCP related complications (odds ratio: 2.40, 95% confidence interval: 1.21-4.75).

CONCLUSIONS

The evidence provided by this meta-analysis suggests that both of these approaches would appear comparable. To fully address which would be the better approach would require an RCT as discussed above.

Comparison between intraoperative cholangiography and choledochoscopy for ductal clearance in laparoscopic CBD exploration: a prospective randomized study

BACKGROUND

Laparoscopic CBD exploration (LCBDE) is an accepted treatment modality for single stage management of CBD stones in fit patients. A transcholedochal approach is preferred in patients with a dilated CBD and large impacted stones in whom ductal clearance remains problematic. There are very few studies comparing intraoperative cholangiography (IOC) with choledochoscopy to determine ductal clearance in patients undergoing transcholedochal LCBDE. This series represents the first of those comparing the two from Asia.

METHODS

Between April 2009 and October 2012, 150 consecutive patients with CBD stones were enrolled in a prospective randomized study to undergo transcholedochal LCBDE on an intent-to-treat basis. Patients with CBD diameter of less than 9 mm on preoperative imaging were excluded from the study. Out of the 132 eligible patients, 65 patients underwent IOC (Group A), and 67 patients underwent intraoperative choledochoscopy (Group B) to determine CBD clearance.

RESULTS

There were no differences between the two groups in the demographic profile and the preoperative biochemical findings. There was no conversion to open procedures, and complete stone clearance was achieved in all the 132 cases. The mean CBD diameter and the mean number of CBD stones removed were comparable between the two groups. Mean operating time was 170 min in Group A and 140 min in Group B (p < 0.001). There was no difference in complications between the two groups. Nine patients in Group A (13.8%) showed non-passage of contrast into the duodenum on IOC which resolved after administration of i.v. glucagon, suggesting a transient spasm of sphincter of Oddi. Two patients (3%) showed a false-positive result on IOC which had to be resolved with choledochoscopy.

CONCLUSIONS

The present study showed that intraoperative choledochoscopy is better than IOC for determining ductal clearance after transcholedochal LCBDE and is less cumbersome and less time-consuming.

Laparoscopic treatment for unsuspected common bile duct stones by transcystic sphincter of Oddi pneumatic balloon dilation and pressure-washing technique

BACKGROUND

Unsuspected common bile duct stones (CBDS) are found in 4-5 % of patients with cholelithiasis. The optimal strategy for the treatment of asymptomatic CBDS, diagnosed during laparoscopic cholecystectomy (LC), is not yet well established. A one-stage solution is preferable to solve the CBDS during the LC and to avoid the exposure of patients to the risks of a second procedure, such as complications or failure.

METHODS

We attempted to remove CBDS by transcystic sphincter of Oddi pneumatic balloon dilation and common bile duct pressure-washing in all cases of intraoperative identification of CBDS since September 2008.

RESULTS

In 29 cases, unsuspected CBDS was identified by intraoperative cholangiography; in 28 cases a single stone with a mean diameter of 4.3 mm (range = 3-6) was detected and in one case three 5-8-mm-diameter stones were identified. Clearance of the common bile duct was obtained in 27 cases (96 %), with a mean operative time of 54 min (range = 36-90) and mean length of hospital stay of 2.5 days.

CONCLUSION

Treatment of unsuspected CBDS detected by intraoperative cholangiography during LC with this original technique was safe and effective and a viable alternative of the transcystic endoscopic approach.

Surgical versus endoscopic treatment of bile duct stones

BACKGROUND

Between 10% to 18% of people undergoing cholecystectomy for gallstones have common bile duct stones. Treatment of the bile duct stones can be conducted as open cholecystectomy plus open common bile duct exploration or laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC + LCBDE) versus pre- or post-cholecystectomy endoscopic retrograde cholangiopancreatography (ERCP) in two stages, usually combined with either sphincterotomy (commonest) or sphincteroplasty (papillary dilatation) for common bile duct clearance. The benefits and harms of the different approaches are not known.

OBJECTIVES

We aimed to systematically review the benefits and harms of different approaches to the management of common bile duct stones.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7 of 12, 2013) in The Cochrane Library, MEDLINE (1946 to August 2013), EMBASE (1974 to August 2013), and Science Citation Index Expanded (1900 to August 2013).

SELECTION CRITERIA

We included all randomised clinical trials which compared the results from open surgery versus endoscopic clearance and laparoscopic surgery versus endoscopic clearance for common bile duct stones.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials for inclusion and independently extracted data. We calculated the odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI) using both fixed-effect and random-effects models meta-analyses, performed with Review Manager 5.

MAIN RESULTS

Sixteen randomised clinical trials with a total of 1758 randomised participants fulfilled the inclusion criteria of this review. Eight trials with 737 participants compared open surgical clearance with ERCP; five trials with 621 participants compared laparoscopic clearance with pre-operative ERCP; and two trials with 166 participants compared laparoscopic clearance with postoperative ERCP. One trial with 234 participants compared LCBDE with intra-operative ERCP. There were no trials of open or LCBDE versus ERCP in people without an intact gallbladder. All trials had a high risk of bias.There was no significant difference in the mortality between open surgery versus ERCP clearance (eight trials; 733 participants; 5/371 (1%) versus 10/358 (3%) OR 0.51;95% CI 0.18 to 1.44). Neither was there a significant difference in the morbidity between open surgery versus ERCP clearance (eight trials; 733 participants; 76/371 (20%) versus 67/358 (19%) OR 1.12; 95% CI 0.77 to 1.62). Participants in the open surgery group had significantly fewer retained stones compared with the ERCP group (seven trials; 609 participants; 20/313 (6%) versus 47/296 (16%) OR 0.36; 95% CI 0.21 to 0.62), P = 0.0002.There was no significant difference in the mortality between LC + LCBDE versus pre-operative ERCP +LC (five trials; 580 participants; 2/285 (0.7%) versus 3/295 (1%) OR 0.72; 95% CI 0.12 to 4.33). Neither was there was a significant difference in the morbidity between the two groups (five trials; 580 participants; 44/285 (15%) versus 37/295 (13%) OR 1.28; 95% CI 0.80 to 2.05). There was no significant difference between the two groups in the number of participants with retained stones (five trials; 580 participants; 24/285 (8%) versus 31/295 (11%) OR 0.79; 95% CI 0.45 to 1.39).There was only one trial assessing LC + LCBDE versus LC+intra-operative ERCP including 234 participants. There was no reported mortality in either of the groups. There was no significant difference in the morbidity, retained stones, procedure failure rates between the two intervention groups.Two trials assessed LC + LCBDE versus LC+post-operative ERCP. There was no reported mortality in either of the groups. There was no significant difference in the morbidity between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 13/81 (16%) versus 12/85 (14%) OR 1.16; 95% CI 0.50 to 2.72). There was a significant difference in the retained stones between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 7/81 (9%) versus 21/85 (25%) OR 0.28; 95% CI 0.11 to 0.72; P = 0.008.In total, seven trials including 746 participants compared single staged LC + LCBDE versus two-staged pre-operative ERCP + LC or LC + post-operative ERCP. There was no significant difference in the mortality between single and two-stage management (seven trials; 746 participants; 2/366 versus 3/380 OR 0.72; 95% CI 0.12 to 4.33). There was no a significant difference in the morbidity (seven trials; 746 participants; 57/366 (16%) versus 49/380 (13%) OR 1.25; 95% CI 0.83 to 1.89). There were significantly fewer retained stones in the single-stage group (31/366 participants; 8%) compared with the two-stage group (52/380 participants; 14%), but the difference was not statistically significantOR 0.59; 95% CI 0.37 to 0.94).There was no significant difference in the conversion rates of LCBDE to open surgery when compared with pre-operative, intra-operative, and postoperative ERCP groups. Meta-analysis of the outcomes duration of hospital stay, quality of life, and cost of the procedures could not be performed due to lack of data.

AUTHORS' CONCLUSIONS

Open bile duct surgery seems superior to ERCP in achieving common bile duct stone clearance based on the evidence available from the early endoscopy era. There is no significant difference in the mortality and morbidity between laparoscopic bile duct clearance and the endoscopic options. There is no significant reduction in the number of retained stones and failure rates in the laparoscopy groups compared with the pre-operative and intra-operative ERCP groups. There is no significant difference in the mortality, morbidity, retained stones, and failure rates between the single-stage laparoscopic bile duct clearance and two-stage endoscopic management. More randomised clinical trials without risks of systematic and random errors are necessary to confirm these findings.

Transcystic approach with micro-incision of the cystic duct and its confluence part in laparoscopic common bile duct exploration

BACKGROUND

Laparoscopic transcystic common bile duct exploration has become a safe and ideal treatment of common bile duct stones. This study was designed to explore the clinical value of modified laparoscopic transcystic common bile duct exploration as a first line of treatment for patients with common bile duct stones.

PATIENTS AND METHODS

A retrospective, case-control study of clinically comparable groups of patients who underwent the laparoscopic transcystic approach with micro-incision of the cystic duct and its confluence part in common bile duct exploration (LTM-CBD) (n=110) and laparoscopic common bile duct exploration (LCBD) (n=100) under the care of one surgeon was performed. All clinical data were analyzed retrospectively.

RESULTS

There was no significant difference in terms of operation time between the two groups (P>.05). Postoperative hospital stay and abdominal drainage time were shorter in the LTM-CBD group than in the LCBD group (P<.05). Postoperative bile leakage was seen in 1 case (1 of 110) in the LTM-CBD group and 10 cases (10 of 100) in the LCBD group (P<.05). Twenty patients underwent T-tube drainage in the LCBD group, and primary closure was performed in the other patients; however, all cases in the LTM-CBD group underwent primary closure. The median follow-up was 12 months; 2 patients in the LCBD group who suffered from bile leakage presented with obstructive jaundice due to bile duct stenosis 6 months postoperatively.

CONCLUSIONS

LTM-CBD, which can avoid postoperative T-tube drainage, decrease complications, shorten hospitalization time, and enhance the existing quality, is a minimally invasive, safe, and effective treatment.

Surgical versus endoscopic treatment of bile duct stones

BACKGROUND

Between 10% to 18% of people undergoing cholecystectomy for gallstones have common bile duct stones. Treatment of the bile duct stones can be conducted as open cholecystectomy plus open common bile duct exploration or laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC + LCBDE) versus pre- or post-cholecystectomy endoscopic retrograde cholangiopancreatography (ERCP) in two stages, usually combined with either sphincterotomy (commonest) or sphincteroplasty (papillary dilatation) for common bile duct clearance. The benefits and harms of the different approaches are not known.

OBJECTIVES

We aimed to systematically review the benefits and harms of different approaches to the management of common bile duct stones.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7 of 12, 2013) in The Cochrane Library, MEDLINE (1946 to August 2013), EMBASE (1974 to August 2013), and Science Citation Index Expanded (1900 to August 2013).

SELECTION CRITERIA

We included all randomised clinical trials which compared the results from open surgery versus endoscopic clearance and laparoscopic surgery versus endoscopic clearance for common bile duct stones.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials for inclusion and independently extracted data. We calculated the odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI) using both fixed-effect and random-effects models meta-analyses, performed with Review Manager 5.

MAIN RESULTS

Sixteen randomised clinical trials with a total of 1758 randomised participants fulfilled the inclusion criteria of this review. Eight trials with 737 participants compared open surgical clearance with ERCP; five trials with 621 participants compared laparoscopic clearance with pre-operative ERCP; and two trials with 166 participants compared laparoscopic clearance with postoperative ERCP. One trial with 234 participants compared LCBDE with intra-operative ERCP. There were no trials of open or LCBDE versus ERCP in people without an intact gallbladder. All trials had a high risk of bias.There was no significant difference in the mortality between open surgery versus ERCP clearance (eight trials; 733 participants; 5/371 (1%) versus 10/358 (3%) OR 0.51;95% CI 0.18 to 1.44). Neither was there a significant difference in the morbidity between open surgery versus ERCP clearance (eight trials; 733 participants; 76/371 (20%) versus 67/358 (19%) OR 1.12; 95% CI 0.77 to 1.62). Participants in the open surgery group had significantly fewer retained stones compared with the ERCP group (seven trials; 609 participants; 20/313 (6%) versus 47/296 (16%) OR 0.36; 95% CI 0.21 to 0.62), P = 0.0002.There was no significant difference in the mortality between LC + LCBDE versus pre-operative ERCP +LC (five trials; 580 participants; 2/285 (0.7%) versus 3/295 (1%) OR 0.72; 95% CI 0.12 to 4.33). Neither was there was a significant difference in the morbidity between the two groups (five trials; 580 participants; 44/285 (15%) versus 37/295 (13%) OR 1.28; 95% CI 0.80 to 2.05). There was no significant difference between the two groups in the number of participants with retained stones (five trials; 580 participants; 24/285 (8%) versus 31/295 (11%) OR 0.79; 95% CI 0.45 to 1.39).There was only one trial assessing LC + LCBDE versus LC+intra-operative ERCP including 234 participants. There was no reported mortality in either of the groups. There was no significant difference in the morbidity, retained stones, procedure failure rates between the two intervention groups.Two trials assessed LC + LCBDE versus LC+post-operative ERCP. There was no reported mortality in either of the groups. There was no significant difference in the morbidity between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 13/81 (16%) versus 12/85 (14%) OR 1.16; 95% CI 0.50 to 2.72). There was a significant difference in the retained stones between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 7/81 (9%) versus 21/85 (25%) OR 0.28; 95% CI 0.11 to 0.72; P = 0.008.In total, seven trials including 746 participants compared single staged LC + LCBDE versus two-staged pre-operative ERCP + LC or LC + post-operative ERCP. There was no significant difference in the mortality between single and two-stage management (seven trials; 746 participants; 2/366 versus 3/380 OR 0.72; 95% CI 0.12 to 4.33). There was no a significant difference in the morbidity (seven trials; 746 participants; 57/366 (16%) versus 49/380 (13%) OR 1.25; 95% CI 0.83 to 1.89). There were significantly fewer retained stones in the single-stage group (31/366 participants; 8%) compared with the two-stage group (52/380 participants; 14%), but the difference was not statistically significantOR 0.59; 95% CI 0.37 to 0.94).There was no significant difference in the conversion rates of LCBDE to open surgery when compared with pre-operative, intra-operative, and postoperative ERCP groups. Meta-analysis of the outcomes duration of hospital stay, quality of life, and cost of the procedures could not be performed due to lack of data.

AUTHORS' CONCLUSIONS

Open bile duct surgery seems superior to ERCP in achieving common bile duct stone clearance based on the evidence available from the early endoscopy era. There is no significant difference in the mortality and morbidity between laparoscopic bile duct clearance and the endoscopic options. There is no significant reduction in the number of retained stones and failure rates in the laparoscopy groups compared with the pre-operative and intra-operative ERCP groups. There is no significant difference in the mortality, morbidity, retained stones, and failure rates between the single-stage laparoscopic bile duct clearance and two-stage endoscopic management. More randomised clinical trials without risks of systematic and random errors are necessary to confirm these findings.

Does laparoscopic approach impair T-tube-related sinus-tract formation?

PURPOSE

Postoperative morbidity after bile duct exploration with T-tube insertion is mainly related to tube removal and incomplete sinus-tract formation leading to serious complications. Laparoscopic surgery reduces abdominal adhesion formation and diminishes tissue trauma and inflammatory response to surgery, which is essential for sinus-tract formation. This study evaluates if complication rate of T-tube removal is increased after laparoscopic bile duct exploration.

METHODS

Between January 2004 and January 2011, 94 patients underwent a T-tube insertion following choledocolithotomy (44 and 50 patients in the laparoscopic and open surgery group, respectively). Epidemiological data, preoperative characteristics, day of tube removal, and morbidity rates were analyzed.

RESULTS

Global T-tube removal-related biliary complication rate was 14.9% (18.2% in the laparoscopic group vs. 12% in the open surgery group). Although the day of T-tube removal was significantly delayed, there was a slight increased incidence of biliary peritonitis requiring reintervention in the laparoscopic surgery group (6.9% vs. 2%).

CONCLUSIONS

We reveal that T-tube removal is associated with significant morbidity. There was no statistical difference between the laparoscopic and the open surgery group, although global biliary complications after tube removal were slightly increased and bile spillage was worse delimited when T-tube was inserted laparoscopically. Laparoscopic approach may diminish inflammatory response and adherence development and impair, and therefore sinus-tract formation.

Is the end of the T-tube drainage era in laparoscopic choledochotomy for common bile duct stones is coming? A systematic review and meta-analysis

OBJECTIVE

This study aims to compare the efficacy and safety of T-tube free (TTF) versus T-tube drainage (TTD) after laparoscopic common bile duct exploration (LCBDE).

BACKGROUND

LCBDE has been proven to be an effective and preferred treatment approach for uncomplicated choledocholithiasis, and the appropriateness of T-tube placement after laparoscopic choledochotomy for common bile duct (CBD) stones is still under debate.

METHODS

A systematic literature search (PubMed, EMBASE, Science Citation Index, Springer-Link, and Cochrane Central Register of Controlled Trials) was performed. Postoperative complications were evaluated/graded according to the modified Clavien classification. Other variables extracted including primary closures of the CBDs and the associated assistant methods, T-tube types, and placement durations. Stratified and sensitivity analyses were performed both to explore heterogeneity between studies and to assess the effects of the study qualities.

RESULTS

A total of 956 patients from 12 studies were included. The pooled odds ratio for postoperative complications and biliary-specific complications in TTF was found to be 0.59 [95% confidence interval (CI), 0.38-0.91; P = 0.02], 0.62 (95% CI, 0.36-1.06; P = 0.08), respectively, when compared with TTD. Operative time and hospital stay were significantly decreased in the TTF group, with the pooled weighted mean differences being 18.84 minutes (95% CI, -27.01 to 10.67; P < 0.01) and 3.22 days (95% CI, -4.59 to 1.84; P < 0.01), respectively.

CONCLUSIONS

The results of this meta-analysis demonstrate that among patients undergoing laparoscopic choledochotomy for common bile duct stones, primary closure of the CBD alone is superior to TTD; however, there is no significant benefit in terms of primary duct closure with various internal or external drainage techniques. Further randomized controlled trials are eagerly awaited to prove these findings.

[Laparoscopic versus endoscopic primary management of choledocholithiasis. A retrospective case-control study]

BACKGROUND

The aim was to present the long-term results of one-stage laparoscopic procedure for the management of common bile duct (CBD) lithiasis in comparison with the primary endoscopic approach via ERCP.

PATIENTS AND METHODS

A retrospective case-control study was performed to determine the outcome of patients treated for CBD lithiasis (04/1997 - 11/2011). Data of patients with choledocholithiasis undergoing the two treatment modalities - laparoscopic common bile duct exploration plus laparoscopic cholecystectomy (LCBDE + LC, group A, n = 101) versus endoscopic retrograde cholangiopancreatography/sphincterotomy and laparoscopic cholecystectomy (ERCP/S + LC, group B, n = 116) were matched according to their clinical characteristics. Patients of group A underwent either laparoscopic choledochotomy or transcystic exploration. The policy was to convert to open choledochotomy only after the sequential application of the two treatment modalities (laparoscopic/endoscopic procedure) had failed.

RESULTS

No significant difference in morbidity was found between the groups (group A 8% versus group B 11.2%). Conversion to another procedure was mandatory in 12 out of 101 and 17 out of 116 patients of groups A and B, respectively. The mean follow-up period was 7.8 years (range 1-12 years). Effective laparoscopic treatment of CBD stones (cholecystectomy and CBD clearance) was possible in 89 of the 101 patients in group A (88.1%) compared with 99 of the 116 patients in group B (85.4%) after the endoscopic approach.

CONCLUSIONS

This study showes that both - primary endoscopy and one-stage laparoscopic management of CBD lithiasis - are highly effective and safe with comparable results.

Preoperative versus intraoperative endoscopic sphincterotomy in patients with gallbladder and suspected common bile duct stones: system review and meta-analysis

BACKGROUND

Conducting preoperative versus intraoperative endoscopic sphincterotomy in patients with gallbladder and suspected common bile duct stones remains controversial. We conducted a meta-analysis to evaluate the outcomes of preoperative endoscopic sphincterotomy (POES) versus intraoperative endoscopic sphincterotomy (IOES).

METHODS

We searched multiple electronic databases for prospective, randomized, controlled trials related to safety and effectiveness of POES versus IOES. Relative risk ratios (RRs) were estimated with 95 % confidence intervals (CI) based on an intention-to-treat analysis. We considered the following outcomes: clearance rate, postprocedural complications, and hospital stay.

RESULTS

Five trials with 631 patients (318 with POES, 313 with IOES) were analyzed. Although the overall rates of common bile duct stone clearance were similar between POES and IOES (RR 0.96, 95 % CI 0.91-1.01; p = 0.13), the failure rate of common bile duct cannulation during endoscopic retrograde cholangiopancreatography (ERCP) was significantly higher for IOES (RR 2.54, 95 % CI 1.23-5.26; p = 0.01). The pooled RR after POES for overall complication rates was similar to that for IOES (RR 1.56, 95 % CI 0.94-2.59; p = 0.09). However, compared with IOES, the RR risk of ERCP-related complications was significantly higher for POES (RR 2.27, 95 % CI 1.18-4.40, p = 0.01), especially in the patients at high risk of developing post-ERCP pancreatitis. There was no significant difference in morbidity after laparoscopic cholecystectomy or required subsequent open surgery between the two groups. In the subgroup analyses, the RR risks of post-ERCP pancreatitis were significantly higher for POES (RR 4.85, 95 % CI 1.41-16.66, p = 0.01), and mean hospital stay was longer in the POES group (RR 2.22, 95 % CI 1.98-246; p < 0.01). However, the rates of bleeding, perforation, cholangitis, cholecystitis, and gastric ulceration did not differ significantly between POES and IOES.

CONCLUSIONS

With regard to the stone clearance and overall complication rates, POES is equal to IOES in patients with gallbladder and common bile duct stones. However, IOES is associated with a reduced incidence of ERCP-related pancreatitis and results in a shorter hospital stay.