Long-term Outcome of Primary Closure After Laparoscopic Common Bile Duct Exploration Combined With Choledochoscopy. Surg Laparosc Endosc Percutan Tech. 2015;25:250-253. [PMID: 25856136 DOI: 10.1097/sle.0000000000000151]

Comparison of the therapeutic effects of three minimally invasive approaches for laparoscopic cholecystectomy combined with common bile duct exploration-- a 5-year retrospective analysis

OBJECTIVE

The aim of this retrospective study was to explore the indications for three minimally invasive approaches-T-tube external drainage, double J-tube internal drainage, and primary closure-in laparoscopic cholecystectomy combined with common bile duct exploration.

METHODS

Three hundred eighty-nine patients with common bile duct stones who were treated at the Second People's Hospital of Hefei between February 2018 and January 2023 were retrospectively included. Patients were divided into three groups based on the surgical approach used: the T-tube drainage group, the double J-tube internal drainage group, and the primary closure group. General data, including sex, age, and BMI, were compared among the three groups preoperatively. Surgical time, length of hospital stay, pain scores, and other aspects were compared among the three groups. Differences in liver function, inflammatory factors, and postoperative complications were also compared among the three groups.

RESULTS

There were no significant differences among the three groups in terms of sex, age, BMI, or other general data preoperatively (P > 0.05). There were significant differences between the primary closure group and the T-tube drainage group in terms of surgical time and pain scores (P < 0.05). The primary closure group and double J-tube drainage group differed from the T-tube drainage group in terms of length of hospital stay, hospitalization expenses, and time to passage of gas (P <0.05). Among the three groups, there were no statistically significant differences in inflammatory factors or liver function, TBIL, AST, ALP, ALT, GGT, CRP, or IL-6, before surgery or on the third day after surgery (P > 0.05). However, on the third day after surgery, liver function in all three groups was significantly lower than that before surgery (P<0.05). In all three groups, the levels of CRP and IL-6 were significantly lower than their preoperative levels. The primary closure group had significantly lower CRP and IL-6 levels than did the T-tube drainage group (P < 0.05). The primary closure group differed from the T-tube drainage group in terms of the incidences of bile leakage and electrolyte imbalance (P < 0.05). The double J-tube drainage group differed from the T-tube drainage group in terms of the tube dislodgement rate (P < 0.05).

CONCLUSION

Although primary closure of the bile ducts has clear advantages in terms of length of hospital stay and hospitalization expenses, it is associated with a higher incidence of postoperative complications, particularly bile leakage. T-tube drainage and double J-tube internal drainage also have their own advantages. The specific surgical approach should be selected based on the preoperative assessment, indications, and other factors to reduce the occurrence of postoperative complications.

Long-term outcomes of choledochoduodenostomy for choledocholithiasis: increased incidence of postoperative cholangitis after total or distal gastrectomy

PURPOSE

Choledochoduodenostomy (CDD) is performed to treat choledocholithiasis (CDL) cases where endoscopic stone removal is difficult. Recognizing CDD characteristics is important for CDL treatment planning.

METHODS

A total of 116 patients, including 33 patients ≥ 80 years old (29 with previous total gastrectomy, 19 with previous distal gastrectomy, 20 with built-up stones, 19 with periampullary diverticulum, 10 with confluence stones, 8 with repetitive recurrent stones, 4 with hard stones, 3 with endoscopic retrograde cholangiography [ERC] not available due to lack of cooperation, 2 with a history of pancreatitis post-ERC, and 2 in whom ERC could not be performed due to a disturbed anatomy) underwent CDD for CDL. Postoperative complications and long-term outcomes were evaluated.

RESULTS

The in-hospital mortality rate was 0%. The morbidity (grade ≥ IIIA according to the Clavien-Dindo classification) rates in the elderly (≥ 80 years old) and non-elderly (51-79 years old) patients were 3.0% (1/33) and 2.4% (2/83), respectively (p = 0.85). Long-term complications included cholangitis in eight (7%) patients, of which three cases were repetitive and seven had an operative history of total or distal gastrectomy. The incidence of postoperative cholangitis after total or distal gastrectomy was 15% (7/48), which was significantly higher than that involving other causes (1.5%, 1/68; p < 0.01). Two patients with cholangitis after total gastrectomy experienced early recurrence of lithiasis at 2 and 9 months after surgery.

CONCLUSIONS

CDD is safe, even in elderly patients. However, a history of total gastrectomy or distal gastrectomy may increase the incidence of postoperative cholangitis.

A Retrospective Study on the Three-Port Technique of Laparoscopic Common Bile Duct Exploration for the Management of Cholelithiasis and Choledocholithiasis

Background

Laparoscopic cholecystectomy (LC) with laparoscopic common bile duct exploration (LCBDE) is convenient in treating cholelithiasis and choledocholithiasis due to its advantage of accelerated recovery. This retrospective study aimed to summarize the experience of cholelithiasis and choledocholithiasis treatment via three-port approach of LCBDE in Eastern China.

Methods

Patients diagnosed with cholelithiasis and choledocholithiasis between July 2019 and October 2021 were included. Patients who received LC+LCBDE+primary suturing of the common bile duct (CBD) via a three-port approach were assigned to the LCBDE-P group, and those who received LC+LCBDE+T-tube drainage of CBD comprised the LCBDE-T group. The measurement data were compared between the two groups. P-values <0.05 indicated statistical significance.

Results

A total of 88 patients were divided into two groups: LCBDE-P (n=50) and LCBDE-T (n=38). Multiple logistic regression analysis showed that LCBDE-P is associated with a shorter length of stay (OR=0.115, 95% CI: 0.040-0.329, P<0.001) and lower hospitalization costs (OR=0.120, 95% CI: 0.041-0.357, P<0.001). No significant differences between the two groups were detected in the operation time, intraoperative hemorrhage, clearance rate of CBD stones, postoperative liver function, and postoperative complications (P>0.05).

Conclusion

The three-port approach of LCBDE is a safe and feasible strategy for managing cholelithiasis and choledocholithiasis. Compared to LCBDE-T, LCBDE-P reduces the length of hospital stay and medical costs during hospitalization.

[Modern minimally invasive technologies for the treatment of cholelithiasis]

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

Comparative study of three common bile duct closure techniques after choledocholithotomy: safety and efficacy

PURPOSE

T-tube drainage, primary closure, and biliary stenting are the common bile duct closure methods. There is great debate on the optimal duct closure technique after common bile duct exploration. This study aimed to assess the safety and efficacy of the three commonest common bile duct closure methods after common bile duct exploration for common bile duct stone for future generalization.

METHODS

In this analysis, 211 patients with common bile duct stone underwent common bile duct exploration from January 2016 to December 2020. The patients were divided according to common bile duct closure techniques into three groups, including the T-tube drainage group (63 patients), primary duct closure group (61 patients), and antegrade biliary stenting group (87 patients).

RESULTS

The incidence of overall biliary complications and bile leak were statistically significantly lower in the biliary stenting group than in the other two groups. Also, hospital stays, drain carried time, return to normal activity, re-intervention, and re-admission rates were statistically significantly lower in the biliary stenting group than in the other two groups. There were no statistically significant differences regarding operative and choledochotomy time, retained and recurrent stone, stricture, biliary peritonitis, cholangitis, and the cost among the three groups.

CONCLUSIONS

We state that the biliary stenting procedure should be the preferred first option for common bile duct closure after common bile duct exploration when compared with T-tube drainage and primary duct closure.

TRIAL REGISTRATION

ClinicalTrials.gov PRS (Approval No. NCT04264299).

Greater than or equal to 8 mm is a safe diameter of common bile duct for primary duct closure: single-arm meta-analysis and systematic review

Greater than or equal to 8 mm was often used as the safe diameter of primary duct closure (PDC) after laparoscopic common bile duct exploration (LCBDE) in previous studies, but it is impossible to verify the source of this safe diameter, and lack of evidence for the safe diameter of PDC. Hence, this study evaluates the incidence of postoperative complications by single-arm meta-analysis to demonstrate the feasibility of using 8 mm as the safe diameter of PDC, so as to provide reference for clinical selection. Eligible studies were searched by MEDLINE, the Cochrane Library, Embase, and Web of Science from January 1995 to May 2021, investigating eligible literature using PDC after LCBDE for methods of common bile duct closure. The single-arm meta-analysis was analyzed by "meta" package under R 4.0.5, and the pooled incidence of postoperative complications was calculated. Twelve literatures were enrolled in this single-arm meta-analysis including 792 patients. The pooled complications rate including total complications (13.1%, 95% CI 10.1-15.6%), total biliary duct-related complications (9.4%, 95% CI 7.4-11.6%), residual stones (1.3%, 95% CI 0.3-2.7%), bile leakage (5.1%, 95% CI 3.5-6.9%), postoperative pneumonia (2.1%, 95% CI 0.8-3.8%), postoperative acute pancreatitis (1.8%, 95% CI 0.2-4.3%), and stone recurrence (2.6%, 95% CI 1.1-4.4%). The clinical indication of PDC after LCBDE should follow that the diameter of common bile duct ≥ 8 mm as the safe diameter.

A UK survey on variation in the practice of management of choledocholithiasis and laparoscopic common bile duct exploration (ALiCE Survey)

BACKGROUND

The practice of managing suspected/confirmed common bile duct stones (CBDS) can vary significantly in the UK. We aimed to assess this variability in practice and challenges to form a basis for future consensus.

METHODS

An electronic survey containing 40 questions on various aspects of management of CBDS was sent to surgeons who perform cholecystectomies via five surgical associations.

RESULTS

 A total of 132 surgeons responded to the survey. The speciality of surgeons includes upper gastro-intestinal (68%), general (18%), colorectal (12%), and others (2%). For patients with suspected CBD stones, 80% would choose magnetic resonance cholangio-pancreatography, and 14.4% would proceed to intra-operative imaging. Most surgeons preferred intra-operative cholangiogram over intra-operative ultrasound (83% vs 17%). For the treatment, 62.1% preferred a two-stage approach [endoscopic retrograde cholangio-pancreatography (ERCP) followed by laparoscopic cholecystectomy (LC)] and 33.4% chose a single-stage approach [LC + laparoscopic common bile duct exploration (LCBDE)]. Eighty (60.6%) responders performed LCBDE, and 19 (23.8%) of them performed > 10 LCBDEs in a year. Two third of surgeons (62.5%) preferred a trans-choledochal approach to CBDS. Half of the surgeons that perform LCBDE use a T-tube selectively and 1.6% routinely. The "availability of very good ERCP service" and "lack of formal training" were the two main reasons for surgeons not performing LCBDE. Both surgeons' speciality and whether they perform other complex laparoscopic surgery were significantly associated with choosing a two-stage approach over a one-stage approach (χ² test, speciality p = 0.033, complex surgery p = 0.011).

CONCLUSION

 Our survey confirms the significant variability in the diagnosis and management of CBDS. The two-stage approach is still the most common way of managing CBDS in the UK. The main reasons for the low uptake of the single-stage approach are the availability of good ERCP service, lack of equipment and lack of formal training in the technique of LCBDE.

Primary duct closure versus T-tube drainage after laparoscopic common bile duct exploration: a meta-analysis

BACKGROUND AND AIMS: Laparoscopic common bile duct exploration (LCBDE) is considered a safe and effective method for the removal of bile duct stones. However, the choice of primary duct closure (PDC) or T-tube drainage (TTD) technique after LCBDE is still controversial. This study aimed to compare the safety and effectiveness of PDC and TTD after LCBDE. METHODS: Studies published before May 1, 2021 in PubMed, Web of Science, and Cochrane Library databases were searched to screen out randomized controlled trials (RCTs) and cohort studies to compare PDC with TTD. Meta-analyses of fixed effect and random effect models were performed using RevMan 5.3. RESULTS: A total of 1865 patients were enrolled in six RCTs and ten cohort studies. Regarding RCTs, the PDC group was significantly better than the TTD group in terms of operation time, total postoperative complications, postoperative hospital stay, and hospitalization expenses (all P<0.05). Based on cohort studies of the subgroup, the PDC group had shorter operation time, shorter postoperative hospital stay, less intraoperative blood loss, and limited total postoperative complications. Statistically, there were no significant differences in bile leakage, retained stones, stone recurrence, bile duct stricture, postoperative pancreatitis, other complications, or postoperative exhaust time between the TTD and PDC groups. CONCLUSIONS: Based on the available evidence, compared with TTD, PDC is safe and effective, and can be used as the first choice after transductal LCBDE in patients with choledocholithiasis.

Efficacy and safety of laparoscopic common bile duct exploration via choledochotomy with primary closure for the management of acute cholangitis caused by common bile duct stones

Background

T-tube drainage after laparoscopic common bile duct exploration (LCBDE) has been demonstrated to be safe and effective for patients with acute cholangitis caused by common bile duct stones (CBDSs). The outcomes after LCBDE with primary closure in patients with CBDS-related acute cholangitis are unknown. The present study aimed to evaluate the efficacy and safety of LCBDE with primary closure for the management of acute cholangitis caused by CBDSs.

Methods

Between June 2015 and June 2020, 368 consecutive patients with choledocholithiasis combined with cholecystolithiasis, who underwent laparoscopic cholecystectomy (LC) + LCBDE in our department, were retrospectively reviewed. A total of 193 patients with CBDS-related acute cholangitis underwent LC + LCBDE with primary closure of the CBD (PC group) and 62 patients underwent LC + LCBDE followed by T-tube placement (T-tube group). A total of 113 patients who did not have cholangitis were excluded. The clinical data were compared and analyzed.

Results

There was no mortality in either group. No significant differences were noted in morbidity, bile leakage rate, retained CBD stones, or readmission rate within 30 days between the two groups. Compared with the T-tube group, the PC group avoided T-tube-related complications and had a shorter operative time (121.12 min vs. 143.37 min) and length of postoperative hospital stay (6.59 days vs. 8.81 days). Moreover, the hospital expenses in the PC group were significantly lower than those in the T-tube group ($4844.47 vs. $5717.22). No biliary stricture occurred during a median follow-up of 18 months in any patient. No significant difference between the two groups was observed in the rate of stone recurrence.

Conclusions

LCBDE with primary closure is a safe and effective treatment for cholangitis caused by CBDSs. LCBDE with primary closure is not inferior to T-tube drainage for the management of CBDS-related acute cholangitis in suitable patients.

Laparoscopic treatment of a recurrent biliary stone forming around a Hem-o-lok clip in a patient with previous gastrectomies: Case report

RATIONALE

A history of gastrectomy is associated with an increased incidence of gallstones requiring surgery. Endoscopic retrograde cholangiopancreatography is challenging for patients who undergo total or Billroth II gastrectomy. Laparoscopic common bile duct exploration (LCBDE) has been attempted in such cases. Herein, we report a case of choledocholithiasis in which a stone formed around a migrated Hem-o-lok clip.

PATIENT CONCERNS

A 67-year-old man was admitted to the hospital for acute right upper abdominal pain. He had a history of 2 open gastric cancer surgeries in the previous seven years and had undergone LCBDE 12 months prior to this admission. Postoperative examination revealed recurrence of bile duct stones.

INTERVENTIONS

The patient underwent repeat LCBDE plus primary closure with an evaluation of abdominal adhesion. A stone had formed around a Hem-o-lok clip in the common bile duct was removed.

OUTCOMES

The patient had an uneventful recovery with no stone recurrence or movement of the remaining Hem-o-lok clips after a 1-year follow-up.

LESSONS

LCBDE with primary closure should be carefully considered in patients with certain gallstone diseases after complicated upper abdominal surgery.Postoperative clip migration is a rare complication; hence care must be taken in placing the clip appropriately to ensure that it is not too close to the common bile duct.

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.

Primary Suture of the Common Bile Duct: Continuous or Interrupted?

Objective: To compare the effectiveness and safety of continuous suture and interrupted suture in Laparoscopic Common Bile Duct Exploration (LCBDE) for choledocholithiasis. Materials and Methods: The data of 125 patients with choledocholithiasis treated with LCBDE in our department from January 2017 to January 2019 were retrospectively collected and divided into two subgroups: the continuous suture group (n = 56) and the interrupted suture group (n = 69). The operation duration, time to suture, intraoperative blood loss, extubation time, hospital stay, total hospitalization expenses, preoperative and postoperative diameters of the common bile duct (CBD), and the occurrence rate of postoperative complications were all compared between the two groups. Results: The operative duration, time to suture, and intraoperative blood loss in the continuous suture group were less compared with those in the interrupted suture group (P < .05). There was no statistical significance between the 2 groups considering extubation time, hospital stay, total hospitalization expenses, and the occurrence rate of postoperative complications (P > .05). The postoperative CBD diameters in both groups were significantly larger than the preoperative CBD diameters (P < .05). Conclusions: The continuous suture technique shortened the operative duration, time to suture, and reduced intraoperative blood loss. It proves to be an effective and safe method in patients diagnosed with CBD stones.

Laparoscopic common bile duct exploration with primary closure is beneficial for patients with previous upper abdominal surgery

BACKGROUND

Previous upper abdominal surgery (PUAS) is considered a contraindication to laparoscopic surgery. Whether LCBDE-PC is feasible and beneficial for patients with PUAS remains unclear. This study aimed to evaluate the feasibility and benefits of LCBDE-PC for patients with PUAS.

METHODS

From June 2011 to September 2019, 1167 patients who underwent laparoscopic procedures for choledocholithiasis were reviewed retrospectively. Perioperative outcomes were compared between patients with and without PUAS in un-matched and matched cohorts.

RESULTS

LCBDE-PC was performed successfully in 88.3% of patients with PUAS, and 92.5% of patients without PUAS (P > 0.05). Multivariate analysis showed that PUAS was not a risk factor that affected successful performance of LCBDE-PC. Although a higher rate of conversion to open surgery and longer operative time were observed in patients with PUAS, no significant differences were found between patients with and without PUAS in multivariate and propensity score analysis (P > 0.05). A predictive nomogram for LCBDE-PC failure was developed based on potential predictors from the least absolute shrinkage and selection operator (LASSO) regression model. Successful performance of LCBDE-PC was associated with operative time. A linear regression model for operative time showed impacted stone in the CBD and intraoperative laser use was the most important factor in determining the operative time.

CONCLUSION

LCBDE-PC is feasible and beneficial for patients with PUAS. However, patients with PUAS with a high possibility of LCBDE-PC failure from the nomogram and a longer operative time from the linear regression model should be cautious when undergoing LCBDE-PC.

The Safety and Efficacy of Primary Duct Closure without Endoscopic Nasobiliary Drainage after Laparoscopic Common Bile Duct Exploration

Background

Primary duct closure (PDC) after laparoscopic common bile duct exploration (LCBDE) has been widely applied for choledocholithiasis. However, there has been controversy over the placement of endoscopic nasobiliary drainage (ENBD) during operation. To date, few studies compare the clinical effect of PDC without and with ENBD. The aim of this study was to assess the safety and efficacy of PDC without ENBD for choledocholithiasis.

Methods

From January 2016 to December 2018, a total of 164 patients meeting the inclusion criteria were enrolled and divided into group A (undergone LCBDE + PDC without ENBD, 81 cases) and group B (undergone LCBDE + PDC with ENBD, 83 cases) in this study. The intraoperative conditions and postoperative complications were compared between the 2 groups.

Results

In group A, the time of operation, postoperative first flatus, extubation, antibiotics, and discharge were shorter than in group B (t = -17.775, p = 0.000; t = -7.649, p = 0.000; t = -5.807, p = 0.000; t = -9.247, p = 0.000; t = -9.322, p = 0.000, respectively). Furthermore, intraoperative blood loss was less (t = -2.199, p = 0.029) and hospital costs were lower (t = -6.685, p = 0.000). However, there was no significant difference in postoperative complications between the 2 groups (p > 0.05).

Conclusions

In patients who meet the screening criteria, PDC without ENBD after LCBDE is safe and effective and worthy of clinical application.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Can T-tube drainage be replaced by primary suture technique in laparoscopic common bile duct exploration? A meta-analysis of randomized controlled trials

BACKGROUND

Although laparoscopic common bile duct exploration (LCBDE) is considered the best treatment and has the advantages of being minimally invasive for common bile duct (CBD) stones, the choice of T-tube drainage (TTD) or primary duct closure (PDC) after LCBDE is still controversial. Therefore, the aim of the study was to compare the superiority of PDC versus TTD after LCBDE for choledocholithiasis.

METHODS

All potential studies which compare the surgical effects between PDC with TTD were electronically searched for in PubMed, Web of Science, and the Cochrane library databases up to November 2019. Data synthesis and statistical analysis were carried out using RevMan 5.3 software.

RESULTS

In total, six randomized controlled trials with 604 patients (307 in the PDC group and 297 in the TTD group) were included in the current meta-analysis. As compared with the TTD group, the pooled data showed that PDC group had shorter operating time (WMD = -24.30; 95% CI = -27.02 to -21.59; p < 0.00001; I² = 0%; p < 0.88), less medical expenditure (WMD = -2255.73; 95% CI = -3330.59 to -1180.86; p < 0.0001; I² = 96%; p < 0.00001), shorter postoperative hospital stay (OR = -2.88; 95% CI = -3.22 to -2.54; p < 0.00001; I² = 60%; p < 0.03), and lower postoperative complications (OR = 0.49; 95% CI = 0.31 to 0.78; p = 0.77; I² = 0%; p = 0.003). There were no significant differences between the two groups concerning bile leakage (OR = 0.74; 95% CI = 0.36 to 1.53; p = 0.42; I² = 0%; p = 0.90) and retained stones (OR = 0.96; 95% CI = 0.36 to 2.52; p < 0.93; I² = 0%; p < 0.66).

CONCLUSIONS

LCBDE with PDC should be performed as a priority alternative compared with TTD for choledocholithiasis.

Primary Closure Versus T-Tube Drainage Following Laparoscopic Common Bile Duct Exploration in Patients With Previous Biliary Surgery

Laparoscopic common bile duct exploration (LCBDE) has been recently introduced for management of CBD stone in patients with previous biliary surgery history. The aim of this study was to evaluate the safety and effectiveness of primary closure in patients with previous biliary surgery history compared to T-tube drainage. Eighty patients with previous biliary surgery history including laparoscopic cholecystectomy, open cholecystectomy, or open common bile duct exploration were enrolled in the retrospective study. The patients were divided into 2 groups according to the methods of choledochotomy closure. Group A: patients with primary closure after LCBDE (n = 51); group B: patients with T-tube drainage after LCBDE (n = 29). Group A exhibited a shorter postoperative hospital stay and lower hospitalization expenses compared to group B. There was no significant difference in conversion rate to open surgery, operating time, intraoperative blood loss, bile leakage rate, overall complication rate, and stone recurrence rate between the 2 groups. Biliary stricture was not observed in the 2 groups during the follow-up period. Primary closure following LCBDE is safe and effective for the management of CBD stones in patients with previous biliary surgery history.

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.

Laparoscopic Common Bile Duct Exploration With Primary Closure After Failed Endoscopic Retrograde Cholangiopancreatography Without Intraoperative Cholangiography: A Case Series from a Referral Center in Bogota, Colombia

Background: Despite the effectiveness of laparoscopic common bile duct (CBD) surgery, no case series details the use and advantages of laparoscopic CBD exploration (LCBDE) without use of intraoperative cholangiography (IOC) in endoscopic retrograde cholangiopancreatography (ERCP) failure. Therefore, we present a case series regarding our success with LCBDE in managing CBD stones (CBDSs) using laparoscopic technique without IOC. Materials and Methods: We performed a descriptive retrospective observational study. Patients with CBDSs, alone or along with gallbladder stones, were treated through LCBDE with primary CBD closure after failed ERCP. Results: All patients underwent LCBDE with choledocotomy and primary duct closure. Patients with gallbladder stones underwent laparoscopic cholecystectomy (78%). All procedures were successful, and no conversions occurred. Surgery duration averaged 106 minutes. Intraoperative bleeding averaged 15 cc, and no mortalities occurred. No patients required additional surgery or intensive care unit admission. Hospitalization duration averaged 5 days. Conclusions: Therefore, a laparoscopic approach with primary CBD closure after failed ERCP for complex CBDSs is safe and effective.

Primary closure with knotless barbed suture versus traditional T-tube drainage after laparoscopic common bile duct exploration: a single-center medium-term experience

Objective

Primary closure of the common bile duct (CBD) after laparoscopic CBD exploration (LCBDE) is a technical challenge. The present study was performed to evaluate the safety and effectiveness of this surgical method.

Methods

This retrospective study of surgical efficacy and safety involved 79 patients who underwent primary CBD closure with a knotless unidirectional barbed suture or traditional T-tube drainage after LCBDE for CBD stones.

Results

The average suturing time, operation time, and postoperative hospital stay were significantly shorter in the primary closure group than T-tube group. There were no significant differences in the mean diameter of the CBD, number of stones, or incidence of postoperative complications between the two groups. No patients developed recurrence of CBD stones during the median follow-up of 21.5 months.

Conclusions

After LCBDE and intraoperative choledochoscopy, primary closure with knotless unidirectional barbed sutures is a safe and effective therapeutic option for patients with cholelithiasis and concurrent CBD stones. This is especially true when the CBD is dilated more than 8 mm.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Choledocholithiasis recurrence following laparoscopic common bile duct exploration

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Hem-o-lok clip found in the common bile duct 3 years after laparoscopic cholecystectomy and surgical exploration

Endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction is a common and preferred choice for gallstone disease. Laparoscopic common bile duct exploration (LCBDE) and laparoscopic cholecystectomy (LC) are being increasingly used for managing choledocholithiasis and cholecystolithiasis. We report a case of a Hem-o-lok clip that was dropped into the common bile duct (CBD) after LC and surgical common bile duct exploration (CBDE). An 84-year-old man presented with right upper quadrant pain and jaundice for 2 months, and chills and hyperpyrexia for 1 day. The patient had received ERCP and surgical CBDE at a local hospital 3 years previously. The patient first received ERCP and endoscopic nasobiliary drainage (ENBD). When laboratory tests were normal, the patient then received LCBDE. During exploration, stones and a Hem-o-lok clip in the CBD were removed. The patient made good progress after LCBDE + T-tube placement and was discharged from hospital. The findings from this case suggest the following: 1) an appropriate therapy method should be considered for certain gallstone diseases, especially for choledocholithiasis and cholecystolithiasis; and 2) a Hem-o-lok clip should be carefully used during laparoscopic or robot-assisted surgery and the Hem-o-lok clip should not be in close proximity to the incision on the CBD.

The reasonable drainage option after laparoscopic common bile duct exploration for the treatment of choledocholithiasis

OBJECTIVE

To obtain a reasonable drainage after laparoscopic common bile duct exploration (LCBDE) for the treatment of choledocholithiasis.

METHODS

Data of 350 consecutive patients who underwent LCBDE in our hospital from January 2014 to December 2016 were retrospectively reviewed. All the patients were divided into three groups according to different drainage types after LCBDE, including T-tube group with 116 cases, primary closure (PC) group with 114 cases and stent insertion group with 120 cases. Operative parameters and outcomes were compared.

RESULTS

The operative time was no significant difference between the T-tube group (106.71 ± 5.19 min), PC group (105.46 ± 5.77 min) and stent insertion group (106.88 ± 5.91 min) (F = 2.175, P = 0.115). The postoperative hospital stay was significantly shorter in the stent insertion group (5.62 ± 0.70 d) than in the T-tube group (7.79 ± 0.85 d) and PC group (7.60 ± 0.80 d) (F = 279.649, P = 0.000). The hospitalization cost was significantly less in the stent insertion group (19,432.78 ± 661.74 yuan) than in the T-tube group (22,059.90 ± 697.98 yuan) and PC group (21,927.20 ± 772.02 yuan) (F = 512.492, P = 0.000). The incidence of postoperative biliary-specific complications was 2.59% (3/116 cases) in the T-tube group, 2.63% (3/114 cases) in the PC group, and 0% (0/120 cases) in the stent insertion group, but this difference was not statistically significant (χ² = 3.177, P = 0.204). The return to normal levels of postoperative liver function tests (LFTs) was significantly faster in the stent insertion group and T-tube group than in the PC group (P < 0.05). The number of 314 patients were followed up for a median time of 20 months (range from 1-48 months), and no biliary stricture, cholangitis or stone recurrence occurred in these patients during that time.

CONCLUSIONS

Stent insertion shows better results when compared with T-tube drainage and primary duct closure in terms of postoperative hospital stay and hospitalization cost. It is the prior option for the choledochotomy closure after LCBDE in suitable patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Appropriate Patient Selection Is Essential for the Success of Primary Closure After Laparoscopic Common Bile Duct Exploration

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) is being increasingly used for management of common bile duct (CBD) stones. Primary CBD closure has been reported to have better short-term outcomes compared to T-tube placement. However, primary CBD closure cannot be performed in all patients.

AIM

This study aims to evaluate the short- and long-term outcomes of LCBDE with primary CBD closure in appropriately selected patients and compare them with T-tube drainage.

METHODS

Retrospective analysis of patients undergoing LCBDE in our department from June 2011 to October 2014 was performed. Primary closure was performed in 52 patients (group A), and a T-tube was placed in 33 patients (group B). Patient demographics, intraoperative findings, postoperative stay, complications, and long-term follow-up data were recorded and compared.

RESULTS

The mean operating time was much longer in group A compared to group B (113.92 vs. 95.92 min, p = 0.032). The overall complication rate (9.6 vs. 6.3%, p = 0.701) and hospital stay (4 vs. 5.11 days, p = 0.088) were similar in both groups. No patient required conversion to the open procedure. Bile leakage was more frequent in group A (5.78 vs. 0%, p = 0.279), but this was not statistically significant. All three patients with bile leakage were treated successfully by conservative measures and gradual drain withdrawal. On long-term follow-up, recurrent stones were detected in two patients in group A. No patient was found to develop CBD stricture.

CONCLUSION

LCBDE and primary CBD closure has excellent short- and long-term outcomes when performed in appropriately selected patients.

Risk factors for bile leakage after primary closure following laparoscopic common bile duct exploration: a retrospective cohort study

Background

Primary closure following laparoscopic common bile duct exploration (LCBDE) has been widely adopted because of the efficacy and safety in treatment of common bile duct (CBD) stones. However, the risk factors for bile leakage, the most common complication after primary closure, has not been clarified yet.

Methods

A retrospective cohort study of patients who underwent LCBDE with primary closure after choledochotomy between Feb. 2012 and Jun. 2016 was performed. Risk factors for bile leakage were identified by logistic regression inculding demographic factors, preoperative condition and surgical details.

Results

Between Feb. 2012 and Jun. 2016, a total of 265 LCBDE procedures were applied in our hospital and 141 patients with primary closure were included in this study. Bile leakage occurred in 11.3% (16/141) of these patients, and happened more frequently in patients with slender CBD (<1 vs ≥1 cm, 31.6% vs 7.0%, p = 0.04) and those managed by inexperienced surgeons (initial 70 cases vs later cases, 17.1% vs 5.6%, p = 0.04). After multivariable regression, the diameter of CBD [OR 95% CI, 3.799 (1.081–13.349), p = 0.04] and experience of surgeons [OR 95% CI, 4.228 (1.330–13.438), p = 0.03] were significantly related to bile leakage.

Conclusion

Slender CBD and inexperienced surgeons were the high risk factors for bile leakage after primary closure following LCBDE.

A survey of European-African surgeons' management of common bile duct stones

BACKGROUND

Common bile duct (CBD) stones can be managed by either endoscopic retrograde cholangiopancreatography (ERCP) or laparoscopic common bile duct exploration (LCBDE). The aim of this survey was to document the management of CBD stones by European-African HPB Association (E-AHPBA) members.

METHODS

All 331 members of the E-AHPBA were invited by personal email to participate to an online survey.

RESULTS

Ninety-three (28%) surgeons replied within 2 months. Responding surgeons were attending surgeons (84%), working as HPB surgeons (75%) in academic hospitals (73%). In patients with clinically suspected CBD stones, MRCP was the preferred diagnostic test for 61% of respondents. LCBDE was the preferred therapeutic strategy for 11 (12%) respondents only. Previous gastric surgery was an absolute contraindication to ERCP for 47% of respondents. Absence of CBD dilation was considered an absolute contraindication for LCBDE in 24% of respondents. Yearly caseload exceeded 10 patients for only 30% of 56 centers performing LCBDE. The transcystic approach was preferred by 39% of surgeons performing LCBDE. There was considerable variation amongst respondents with regard to type and duration of drainage, bile duct closure technique and follow-up after LCBDE.

CONCLUSION

Indications for single-stage LCBDE are not standardized and do not appear well established across E-AHPBA members.

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

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

Efficacy of laparoscopic vs open common bile duct exploration in patients with choledocholithiasis

AIM: To compare the efficacy between laparoscopic and open common bile duct exploration in patients with choledocholithiasis.

METHODS: Ninety-six patients with choledocholithiasis were divided into a study group (50 cases) and a control group (46 cases). The study group received laparoscopic common bile duct exploration, and the control group received open common bile duct exploration. The operative situation, postoperative situation, and complications were compared for the two groups.

RESULTS: There was no significant difference in operative time or bleeding volume between the two groups (130.33 min ± 11.06 min vs 128.68 min ± 10.88 min, 68.86 mL ± 10.97 mL vs 70.92 mL ± 11.26 mL, P > 0.05). The number of times of postoperative analgesia use, time to gastrointestinal function recovery, postoperative hospitalization duration, and total treatment cost for the study group were significantly lower than those for the control group (1.27 ± 0.50 vs 1.68 ± 0.72, 29.82 h ± 5.69 h vs 34.91 h ± 5.70 h, 7.22 d ± 1.15 d vs 10.11 d ± 1.33 d, 10068.44 ± 113.08 vs 13025.75 ± 116.20, P < 0.05). The rate of incision infection for the experiment group was significantly lower than that for the control group (0.00% vs 8.70%, P < 0.05).

CONCLUSION: Laparoscopic common bile duct exploration is associated with less surgical trauma, shorter postoperative recovery time and lower treatment cost than open common bile duct exploration in patients with choledocholithiasis.