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

Spare the Needle, Discharge the Child: Trending Post-Op Labs After Laparoscopic Common Bile Duct Exploration in Pediatric Patients Is Not Helpful

Laparoscopic common bile duct exploration (LCBDE) utility in management of choledocholithiasis may decrease length of stay and patient cost, but postoperative management remains widely debated. We examined periprocedural LFTs for patients undergoing LCBDE and endoscopic retrograde cholangiopancreatography (ERCP) speculating for trend existence after successful LCBDE. We hypothesized that postoperative LCBDE LFTs would not downtrend even after successful ductal clearance. We identified 99 patients under 18 who underwent ERCP or LCBDE with at least one pre- and post-procedural LFT. Periprocedural LFTs between groups were compared using Wilcoxon signed-rank tests. The 22 ERCP patients demonstrated a significant downtrend across Tbili (P < .001), AST (P = .001), ALT (P = .002), and ALP (P < .001). The 27 LCBDE patients demonstrated a significant downtrend in Tbili (P = .002) only, while AST (P > .05), ALT (P > .05), and ALP (P > .05) were nonsignificant. Lack of consistent downtrend in the LCBDE group raises doubt regarding the utility of postoperative LFTs for post-procedural management.

Resolution of Liver Function Tests After Laparoscopic Common Bile Duct Exploration Versus Endoscopic Retrograde Cholangiopancreatography

Laparoscopic cholecystectomy (LC) with laparoscopic common bile duct exploration (LCBDE) is gaining traction for the management of choledocholithiasis. Liver function tests (LFTs) are often used to determine the success of ductal clearance, yet the impact of differing therapeutic interventions, endoscopic retrograde cholangiopancreatography (ERCP) or LCBDE, have on postprocedure LFT is insufficiently described. We hypothesize that these interventions have different postoperative LFT profiles. The preprocedural and postprocedural total bilirubin (Tbili), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP) were analyzed of 167 patients who had successful ERCPs (117) or LCBDEs (50). Endoscopic retrograde cholangiopancreatography patients demonstrated a significant decrease in all LFTs postprocedure (n = 117; P = <0.001 for all) with a continued downtrend when a second set of LFTs was obtained (n = 102; P = <0.001 for all). For successful LC+LCBDEs, there was no significant change between preoperative and 1st postoperative Tbili, AST, ALT, and ALP and the 2nd postoperative labs.

Comparison of Primary Suture and T-Tube Drainage After Laparoscopic Common Bile Duct Exploration Combined with Intraoperative Choledochoscopy in the Treatment of Secondary Common Bile Duct Stones: A Single-Center Retrospective Analysis

Objective: To compare the safety and feasibility of T-tube drainage and primary suture after laparoscopy combined with choledochoscopy in the treatment of secondary choledocholithiasis. Methods: The clinical data of patients who underwent laparoscopic choledochoscopy combined with choledochoscopic common bile duct exploration (LCBDE) for secondary choledocholithiasis from June 2015 to June 2020 were analyzed retrospectively. According to the different treatment method of common bile duct (CBD) incision, the patients were divided into a T-tube drainage group and a primary suture group. The preoperative clinical characteristics, results of preoperative liver function tests (LFTs), LFTs on the first day after the operation and the fourth day after the operation, operation time, intraoperative bleeding, postoperative complications, and times of postoperative hospital stay were compared between the two groups. Results: There was no significant difference in preoperative clinical data, preoperative LFTs, and postoperative complications between the two groups (P > .05). However, primary suture demonstrated significant advantages (P < .05) in terms of the operation time, intraoperative blood loss, postoperative hospital stay, and other related factors. Bilirubin levels on the first day after the operation and the fourth day after the operation between the two groups suggested that T-tube drainage reduces bilirubin in the short term, but that long-term bilirubin draining is similar between the two strategies. Univariate and multivariate analyses showed that choledochal diameter less than 8 mm was an independent risk factor for bile leakage. Conclusions: Laparoscopy combined with intraoperative choledochoscopic CBD exploration is superior to T-tube drainage in terms of the operation time, intraoperative blood loss, and postoperative hospital stay. The ability of reducing bilirubin by traditional T-tube drainage is indeed better than that of primary suture in the early stage after operation, but there is no difference in long-term outcome between the two groups. Choledochal diameter ≤8 mm was an independent risk factor for bile leakage. To summarize, LCBDEs primary suture for secondary choledocholithiasis is safe and feasible.

Choledocholithiasis-a new clinical pathway

The incidence of cholecystectomy in children has increased considerably since the early 1990s. Management of gallbladder disease in children must include an awareness of choledocholithiasis treatment strategies. Both endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct exploration (open or laparoscopic) are accepted management techniques for choledocholithiasis. Laparoscopic cholecystectomy with preoperative or postoperative ERCP is at least a two-procedure process while cholecystectomy with laparoscopic common bile duct exploration (LCBDE) can provide definitive treatment in a single procedure under one anesthetic. Despite this, the trend over the last decade continues towards less LCBDE utilization in favor of ERCP. This trend has resulted in decreased familiarity with LCBDE by adult and pediatric surgeons and their trainees. Access to the necessary tools and education on the technical aspects can allow for successful single-stage treatment of choledocholithiasis by surgeons during laparoscopic cholecystectomy. This may include a pre-defined stepwise algorithm and understanding of all the equipment and resources necessary to perform a LCBDE. Ultimately, increased understanding of the equipment and procedural steps necessary for LCBDE will result in widened adoption of the technique and thus confer advantages to the patient such as decreased length of stay and fewer required anesthetics.

The Effect of L-Hook Dissection and Scissors Dissection on Liver Injury in Laparoscopic Cholecystectomies

Purpose: Laparoscopic cholecystectomy is generally performed with the help of monopolar cautery. We aimed to reveal the effect of monopolar cautery use on liver damage in this study.

Method: Data of patients who underwent elective cholecystectomy between January 2016 and April 2020 were collected retrospectively. The patients were divided into two groups according to the surgical technique as hook dissection (HD) and scissor dissection (SD). The amount of increase in the preoperative and postoperative alanine aminotransferase (ALT) and aspartate aminotransferase (AST) values of the patients was compared between the two groups.

Findings: Over 970 patients were included in the study. The changes in pre-post ALT and AST values were statistically significantly different between the HD (n=469) and SD (n=501) groups (p<0.001; p0.001). ALT (26 (−25, 338)) and AST (27 (−23, 444)) changes in the HD method were statistically significantly higher than ALT (11 (−16, 371)) and AST (10.8 (−37, 617)) changes in the SD method.

Results: ALT and AST values increase after all laparoscopic cholecystectomies. Although the increase in ALT and AST in the HD patients is statistically significant when compared to the SD group, both methods of laparoscopic cholecystectomy can be safely performed because they do not cause permanent liver injury.