Laparoscopic Transcystic Common Bile Duct Exploration: Advantages over Laparoscopic Choledochotomy

Clinical Evaluation of Primary Suturing of Normal-Diameter Common Bile Ducts After Microincision of Cystic Duct Confluence for Stone Removal

PURPOSE

In patients with gallstones complicated by common bile duct (CBD) stones, both normal and dilated common bile ducts have been reported. The goal of this study was to investigate the efficacy and safety of primary suturing after microincision of the cystic duct confluence in treating these patients.

METHOD

Between July 2018 and December 2021, 104 patients were admitted to the Department of General Surgery at Guannan County People's Hospital with gallstone complications, and their records were reviewed retrospectively. The patients were divided into 2 groups: normal CBD group (n=70, CBD diameter: 6.0 to 8.0 mm) and dilated CBD group (n=34, CBD diameter: >8.0 mm). In these 104 patients, there were 75 cases of CBD stones with acute cholangitis, 12 cases of CBD stones without cholangitis, and 17 cases of mild biliary pancreatitis with CBD stones (including 2 cases of biliary pancreatitis with cholangitis). Among all patients, there were 37 cases with jaundice, 67 cases without jaundice, and 5 cases of emergency surgery. All patients underwent microincision of the cystic duct confluence followed by primary suturing. Both groups were compared on a variety of general and perioperative indicators.

RESULT

All patients underwent laparoscopy combined with choledochoscopy; there were no cases of biliary tract injury or conversion to laparotomy. There was no statistically significant difference in operation duration ( P =0.286), blood loss ( P =0.06), length of stay ( P =0.821), and time to drainage tube removal ( P =0.096) between the 2 groups.

CONCLUSION

Microincision of the cystic duct confluence, followed by a primary suture, is a safe and effective treatment for CBD stones in patients with a normal CBD diameter, as determined by preoperative imaging.

The "Basket-in-Catheter" technique: facilitating transcystic bile duct exploration and optimising the management of suspected ductal stones

The 'Basket-in-Catheter' (BIC) technique facilitates basket-only laparoscopic transcystic exploration (LTCE), increasing its success rate. Using the cholangiography catheter as a sheath is easier and safer than inserting the wire basket-alone. This study evaluates its benefits in confirmed and suspected ductal stones. Retrospective analysis of prospectively collected data on patients with pre-operative or operative suspicion of bile duct stones or with positive and equivocal intraoperative cholangiographies (IOC) who had LTCE attempted using blind basket trawling, without choledochoscopy, were reviewed. The incidence and outcomes of blind basket LTCEs attempted before and after introducing the BIC technique, whether or not stones were retrieved, were analysed. Blind basket LTCE was attempted in 732 patients. Of 377 (51.5%) patients undergoing successful stone retrieval, only 62% had pre-operative clinical and radiological risk factors for ductal stones, 25% had operative risk factors and 13% had silent stones discovered on IOC. Another 355 patients (48.5%) had negative trawling, although one half had pre-operative risk factors for ductal stones and 47.6% had operative risk factors, e.g. cystic duct stones or dilatation. This cohort had equivocal cholangiography in 25.9%. Following basket trawling, repeat IOC confirmed resolution of abnormalities. As no stones were retrieved, these were not considered duct explorations. The BIC technique facilitates safe and speedy bile duct clearance when stones are confirmed, avoiding choledochotomies, without significant complications. BIC duct trawling is also beneficial in patients with suspected ductal stones, helping to resolve equivocal IOCs. It helps surgeons to acquire and consolidate ductal exploration skills.

Laparoscopic common bile duct exploration to treat choledocholithiasis in situs inversus patients: A technical review

Situs inversus (SI) is a rare congenital condition characterized by a mirror-image transposition of the major visceral organs. Since the 1990s, more than one hundred SI patients have been reported to have successfully undergone laparoscopic cholecystectomy. In these cases, the major problem is to overcome is the left-right condition for right-handed surgeons. Laparoscopic common bile duct exploration (LCBDE), an alternative to treat patients with bile duct stones, has shown equivalent efficacy and is less likely to cause pancreatitis than endoscopic retrograde cholangiopancreatography. Recent updated meta-analyses revealed that a shorter postoperative hospital stay, fewer procedural interventions, cost-effectiveness, a higher stone clearance rate, and fewer perioperative complications are additional advantages of LCBDE. However, the technique is technically demanding, even for skilled laparoscopic surgeons. Conducting LCBDE in patients with difficult situations, such as SI, is more complex than usual. We herein review published SI patients with choledocholithiasis treated by LCBDE, including our own experience, and this paper focuses on the technical aspects.

Long-Term Outcomes of Laparoscopic Common Bile Duct Exploration Through Diathermy, Choledochotomy, and Primary Closure: A 6-Year Retrospective Cohort Study

Background and Objective: Choledocholithiasis is a frequent pathology, unfortunately when its endoscopic management fails, there is no consensus of how it should be addressed. The aim of this study was to evaluate the safety, feasibility, and long-term outcomes of laparoscopic common bile duct exploration (LCBDE) using electrosurgery (coagulation) for choledochotomy followed by primary closure after endoscopic treatment failure. Materials and Methods: A retrospective cohort study of patients who underwent LCBDE from 2013 to 2018 was conducted in Bogotá, Colombia. Clinical demographics, operative outcomes, recurrence rate of common bile duct stones, and long-term bile duct complications were analyzed. A descriptive analysis was performed. Results: A total of 168 patients were analyzed. Most of the patients were males (53.37%) with a median age of 73 years with no comorbidities (65%). Stone clearance was successful in 167 patients (99.4%). Nonlethal complications were noted in 3 patients during the surgery or in the immediate postoperative (1.79%) and managed with T-tube or endoscopically. No cases of mortality surgery related were observed. There were no signs of any type of biliary injury or stricture observed in any of the patients during the 24-month follow-up period. Conclusions: LCBDE with diathermy and primary closure is a safe and effective treatment option for choledocholithiasis for failed endoscopic retrograde cholangiopancreatography in terms of long-term outcome as well as short-term outcome.

Laparoscopic Transcystic Common Bile Duct Exploration: 8-Year Experience at a Single Institution

BACKGROUND

Laparoscopic transcystic common bile duct exploration (LTCBDE) is used to treat cholecystolithiasis and choledocholithiasis. This study aimed to investigate the safety, effectiveness and generalisability of LTCBDE in patients with cholecystolithiasis and choledocholithiasis based on our LTCBDE experience within 8 years.

METHODS

Four hundred patients with cholecystolithiasis and choledocholithiasis (including 62 of cholecystolithiasis and choledocholithiasis with common bile duct no-dilatation) treated with LTCBDE at a single centre from January 2014 to February 2022 were retrospectively evaluated. They were divided into the first 200 and last 200 LTCBDE cases. The disease characteristics, cystic duct incision methods, surgical outcomes and follow-up data were analysed retrospectively. Each patient was followed up for > 3 months.

RESULTS

Four hundred patients underwent LTCBDE, including 188 males and 212 females aged from 15 to 91 years (average age: 56 years). LTCBDE was successful in 377 (94.3%) patients, while treatment was converted to laparoscopic choledocholithotomy with T-tube drainage in 23 (5.8%), owing to intraoperative choledochoscope insertion failure. The CBD diameter (10.89 ± 1.76 vs 9.97 ± 2.39, P < 0.05), cystic duct diameter (4.62 ± 1.03 vs 5.03 ± 1.29, P < 0.05), and operation time (164.60 ± 24.30 vs 135.34 ± 30.00, P < 0.05). Residual stones were found in six (1.5%) patients and removed during the second operation; post-operative bile leakage was found in one (0.3%) patient, who was discharged safely after the second operation.

CONCLUSIONS

Phase I LTCBDE is safe and effective in treating cholecystolithiasis and choledocholithiasis. With continuous technological advances, LTCBDE has been effectively promoted and applied.

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).

Lessons learnt from the first 200 unselected consecutive cases of laparoscopic exploration of common bile duct stones at a district general hospital

BACKGROUND

The management of choledocholithiasis evolves with diagnostic imaging and therapeutic technology, facilitating a laparoscopic approach. We review our first 200 cases of laparoscopic exploration of the common bile duct, highlighting challenges and lessons learnt.

METHODS

We retrospectively studied the first 200 cases of laparoscopic cholecystectomy with common bile duct exploration between 2006 and 2019. The database contains demographics, clinicopathological characteristics, diagnostic modalities, operative techniques, duration and outcomes.

RESULTS

We compared two approaches: transcystic vs. transcholedochal in our 200 cases. Choledocholithiasis was suspected preoperatively in 163 patients. 21 cases found no stones. Of the remainder, 111/179 cases were completed via the transcystic route and the remaining were completed transcholedochally (68/179); 25% of the transcholedochal cases were converted from a transcystic approach. CBD diameter for transcystic route was 8.2 vs. 11.0 mm for transcholedochal. Total clearance rate was 84%. Retained or recurrent stones were noted in 7 patients. Length of stay was 5.8 days, 3.5 days in the transcystic route vs. 9.4 days after transcholedochal clearance. Eight patients required re-operation for bleeding or bile leak. No mortalities were recorded in this cohort, but 2 cases (1%) developed a subsequent CBD stricture.

CONCLUSION

Concomitant laparoscopic common bile duct clearance with cholecystectomy is feasible, safe and effective in a district general hospital, despite constraints of time and resources. The transcystic route has a lower complication rate and shorter hospital stay, and hence our preference of this route for all cases. Advancements in stone management technology will allow wider adoption of this technique, benefitting more patients.

Titanium clip migration after cholecystectomy: original technique for laparoscopic transcystic extraction when endoscopic retrograde cholangiopancreatography fails

Surgical clip migration into the common bile duct (CBD) is a rare complication after laparoscopic cholecystectomy (LC). Few cases of surgical clip migration have been reported in the literature, and most of them have been successfully treated with endoscopic retrograde cholangiopancreatography (ERCP). We present a 71-year-old woman with 48 h of abdominal pain, jaundice and fever 6 years after laparoscopic cholecystectomy. She was diagnosed with common bile duct obstruction from surgical clip migration. After failure of ERCP, the patient was successfully treated with an innovative approach by laparoscopic transcystic extraction using endoscopic hose-type biopsy forceps. The presented technique was feasible and safe in expert hands, representing a valuable alternative to avoid the need of a choledochotomy in patients with unsuccessful ERCP.

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.

Dual common bile duct examination with transcystic choledochoscopy and cholangiography in laparoscopic cholecystectomy for suspected choledocholithiasis: a prospective study

BACKGROUND

Detection of common bile duct (CBD) stones is a major objective of intraoperative cholangiography (IOC) in laparoscopic cholecystectomy (LC). We evaluated the feasibility and safety of the routine use of transcystic choledochoscopy following IOC (dual common bile duct examination: DCBDE), which may improve the diagnostic accuracy of CBD stones and facilitate one-stage clearance, in LC for suspected choledocholithiasis.

METHODS

Between May 2017 and November 2018, 38 patients with suspected choledocholithiasis were prospectively enrolled in this study, regardless of whether they underwent endoscopic sphincterotomy. Transcystic choledochoscopy was routinely attempted following IOC in LC.

RESULTS

Five cases were excluded due to cholecystitis, bile duct anomaly, or liver cirrhosis. DCBDE was performed in the remaining 33 patients. The biliary tree was delineated by IOC in all patients. Subsequently, choledochosope was performed in 32 patients except for one who was found to have pancreaticobiliary malunion in IOC. The scope was successfully passed into the CBD in 25 (78.1%) patients. Choledochoscopy detected 3 (9.4%) cases of cystic duct stones and 4 (12.5%) cases of CBD stones which were not identified by IOC. All those stones were removed via cystic duct. There were no intra- and postoperative complications, except for two cases of wound infection and one case of a transient increase in serum amylase.

CONCLUSIONS

DCBDE in LC is a safe and promising approach for intraoperative diagnosis and one-stage treatment of suspected choledocholithasis.

Management of bile duct stones at cholecystectomy: an Australian single-centre experience over 2 years

BACKGROUND

Bile duct stones with an intact gallbladder can be treated with either bile duct exploration at cholecystectomy or endoscopic retrograde cholangiopancreatography (ERCP) before or after cholecystectomy. The aim of this study was to evaluate the management of bile duct stones at cholecystectomy at our institution. We also aimed to identify risk factors for failure of ductal clearance in our series.

METHODS

A retrospective review of 690 laparoscopic cholecystectomies over a 2-year period was performed. Patients who underwent laparoscopic bile duct exploration formed the study population.

RESULTS

Of 69 patients with suspected bile duct stones at cholecystectomy 67 (97%) patients underwent laparoscopic bile duct exploration upfront. Complete ductal clearance was achieved in 52 (78%) patients. Postoperative complications (10/67, 15%) included postoperative bleeding (2/67, 3%), bile leak (1/67, 1%), and superficial wound infection (1/67, 1%). There was no mortality. The mean operative time was 126 min and the median length of stay was 2 (1-4) days. A wider common bile duct (CBD) (≥ 8 mm) increased the risk of failed ductal clearance (OR 4.50; 95% confidence interval (CI) 1.15-19.23).

CONCLUSION

This study found that laparoscopic bile duct exploration can effectively and safely treat bile duct stones suspected at cholecystectomy.

Comparison on the Efficacy of Three Duct Closure Methods after Laparoscopic Common Bile Duct Exploration for Choledocholithiasis

Background

Laparoscopic common bile duct exploration (LCBDE) is currently the best approach for complex cases of choledocholithiasis or the cases of endoscopic retrograde cholangiopancreatography (ERCP) failure. Nevertheless, there is no clear consensus on the optimal duct closure method after LCBDE. The purpose of this study was to evaluate the efficacy of 3 duct closure methods after LCBDE for choledocholithiasis.

Material/Methods

In this analysis, 189 patients with choledocholithiasis underwent LCBDE between June 2014 and December 2018. According to different duct closure methods, these patients were divided into T-tube drainage (TTD) group (n=66), common suture group (n=64) and barbed suture group (n=59). The operation time, suturing time, amount of intraoperative bleeding, tube-carried time, length of stay (LOS), hospitalization costs, pre- and post-operative common bile duct (CBD) diameters were all compared among the 3 groups. Six months after discharge, the incidence of complications and recurrent stones was observed.

Results

The operation time, suturing time, and amount of intraoperative bleeding in barbed suture group were both significantly less than those in the common suture group and the TTD group (P<0.01). When compared with the TTD group, the suturing time, tube-carried time, and LOS were decreased markedly in the common suture group and the barbed suture group (P<0.01). The post-operative CBD diameters in the 3 groups were all significantly larger than the pre-operative CBD diameters (P<0.01). There was no statistical significance among the 3 groups regarding the incidence of complications and recurrent stones (P>0.05).

Conclusions

Barbed suture shortened the suturing time, operation time, tube-carried time, and LOS, and lessened the amount of intraoperative bleeding in patients with choledocholithiasis after LCBDE. It was more effective than the common suture and TTD.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Laparoendoscopic rendezvous versus ERCP followed by laparoscopic cholecystectomy for the management of cholecysto-choledocholithiasis: a retrospectively cohort study

BACKGROUND

There are a variety of strategies for the treatment of patients with cholecysto-choledocholithiasis (CCL). Although the surgical approach of choice is preoperative ERCP and laparoscopic cholecystectomy (ERCP + LC), controversy remains regarding which procedure is optimal for CCL.

METHODS

To evaluate the safety and effectiveness of laparoendoscopic rendezvous (LERV) versus ERCP + LC for CCL, a total of 528 patients with CCL were retrospectively studied from January 2013 to December 2018. The patients were scheduled to undergo either the LERV or ERCP + LC procedure. The LERV group included 123 cases, whereas the ERCP + LC group contained 137 cases. The incidence of postoperative complications, success of stone clearance, length of hospital stay, and hospitalization charges were statistically analyzed.

RESULTS

The incidence of pancreatitis was lower in the LERV group than in the ERCP + LC group (3/123 vs. 12/137, P = 0.0291). The median level of post-ERCP amylase was much lower in the LERV group (202.5 U/dL vs. 328.1 U/dL, P < 0.01). However, there was no significant difference in the stone clearance rate or other early complications between the two groups. Further study showed that the length of hospital stay and cost in the LERV group were less than those in the ERCP + LC group (12 days vs. 18 days, P < 0.01; 53591.4¥ vs. 60089.2¥, P < 0.01). In addition, more patients in the two-stage procedure group experienced later biliary complications compared with those in the one-stage approach group (34/137 vs. 4/123, P < 0.05). However, the median operation time was 107.7 min in the two-stage group and 139.8 min in the one-stage group (P < 0.05).

CONCLUSIONS

The LERV technique is a safe and effective approach for CCL with lower pancreatitis; it was associated with few later biliary complications, shortened hospital stays, and fewer charges but significantly longer operative time.

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.

Novel Technique for Laparoscopic Common Bile Duct Exploration Using Endovascular Instrumentation

Treatment of choledocholithiasis is sometimes a two-step process involving both surgeons and gastroenterologists. Common bile duct (CBD) exploration can be performed at the same time as cholecystectomy but often requires the use of rigid tools, increasing the risk of CBD damage. Here, we report the case of a 64-year-old man who presented with epigastric pain and a positive Murphy's sign. Ultrasonography revealed cholecystitis with cholelithiasis. Gangrenous cholecystitis was visualized upon surgical exploration, and an intraoperative cholangiogram diagnosed likely choledocholithiasis. Cholecystectomy was completed, and CBD exploration was performed by the manipulation of endovascular equipment using a trans-cystic approach through to the ampulla of Vater, and the patient made a complete recovery without complications. The substantial flexibility, gentleness, and durability of endovascular instruments allow for minimal tension on structures during the removal of gallstones from the CBD, providing safe, definitive treatment for choledocholithiasis during cholecystectomy.

Hand-assisted laparoscopic splenectomy is a useful surgical treatment method for patients with excessive splenomegaly: A meta-analysis

BACKGROUND

Hand-assisted laparoscopic splenectomy (HALS) can help overcome the drawbacks of laparoscopic splenectomy (LS) while maintaining its advantages.

AIM

To evaluate the efficacy and advantages of HALS for splenomegaly.

METHODS

The relevant literature was reviewed using the PubMed, EMBASE, Cochrane, Ovid Medline, and Wanfang databases to compare the clinical outcomes of HALS and LS. Odds ratios or mean differences were calculated with 95% confidence intervals for fixed-effects and random-effects models. Overall, 754 patients from 16 trials who met the inclusion criteria were selected.

RESULTS

In pure splenectomy, blood loss volume (P < 0.001) and conversion rate (P = 0.008) were significantly lower in the HALS group than in the LS group. Conversely, for splenomegaly, the operative time (P = 0.04) was shorter and blood loss volume (P < 0.001) and conversion rate (P = 0.001) were significantly lower in the HALS group than in the LS group. However, no significant difference was observed in hospital stay length, blood transfusion, time to food intake, complications, or mortality rate between the two groups. Moreover, in splenectomy and devascularization of the upper stomach (DUS), the operative time (P = 0.04) was significantly shorter and blood loss volume (P < 0.001) and conversion rate (P = 0.05) were significantly lower in the HALS + DUS group than in the LS + DUS group. However, no significant difference was observed in hospital stay length, timing of diet, and complications between the two groups.

CONCLUSION

HALS is an ideal surgical treatment method for splenomegaly because it can maximize the benefits for patients while maintaining the advantages of LS.

Single-stage approach for the management of choledocolithiasis with concomitant cholelithiasis. Implementation of a protocol in a secondary hospital

BACKGROUND

Current evidence shows that single-stage treatment of concomitant choledocholithiasis and cholelithiasis is as effective and safe as two-stage treatment. However, several studies suggest that single-stage approach requires shorter hospitalization time and is more cost-effective than the two-stage approach, even though it requires considerable training. This study aimed to evaluate the implementation of a protocol for managing concomitant choledocholithiasis and cholelithiasis using single-stage treatment.

METHODS

A prospective cohort study of patients diagnosed with cholelithiasis and choledocholithiasis who were treated with the single-stage treatment - transcystic instrumentation, choledocotomy or intraoperative endoscopic retrograde cholangiopancreatography (ERCP) - between September 2010 and June 2017 was assessed. The primary outcomes were complications, hospital stay, operative time and recurrence rate.

RESULTS

164 patients were enrolled. 141 (86%) were operated laparoscopically. Preoperatively diagnosed stones were not found by intraoperative imaging or disappeared after "flushing" in 38 patients (23.2%). Surgical approach was transcystic in 45 patients (27.41%), choledochotomy in 74 (45.1%), intraoperative ERCP in 4 (2.4%), and bilioenteric derivation in 3 (1.8%). Mean hospitalization stay was 4.4 days. Mean operative time was 166 min 27 patients (16.5%) had complications and 1 patient was exitus (0.6%). Recurrence rate was 1.2%.

CONCLUSIONS

Single-stage approach is a safe and effective management option for concomitant cholelithiasis and choledocolithiasis. Furthermore, a significant number of common bile duct stones pass spontaneously to duodenum or can benefit from a transcystic approach, with presumable low morbidity and cost-efficiency.

Percutaneous extraction of residual post-cholecystectomy gallstones through the T-tube tract

Purpose

In the present study, the effectiveness and safety of minimally invasive percutaneous extraction of residual post-cholecystectomy gallstones through the T-tube tract were assessed.

Material and methods

Between 2000 and 2015, 12 patients (seven women and five men, mean age 78 ± 8 years) after open cholecystectomy with common bile duct exploration and T-tube drainage underwent percutaneous extraction of residual gallstones through the T-tube tract.

Results

The intervention was successful in 92% (11/12). In seven patients complete extraction of the retained gallstones was achieved, and in four cases partial extraction combined with passage of small residual fragments to the duodenum was obtained. In one case the extraction attempt was ineffective. Mild haemobilia was observed in two patients. No mortality or major complications were observed.

Conclusions

Our findings are consistent with literature data and confirm that percutaneous extraction of residual post-cholecystectomy gallstones through the T-tube tract is an effective and safe treatment method. Although the presented technique is not a novel approach, it can be beneficial in patients unsuitable for open surgery or laparoscopic intervention when ERCP attempt occurs ineffective or there exist contraindications to ERCP.

Transcystic versus traditional laparoscopic common bile duct exploration: its advantages and a meta-analysis

BACKGROUND

The best approach for treating common bile duct stones remains a matter of debate. Traditional laparoscopic common bile duct exploration (LCBDE) can cause adverse events such as stenosis of the bile duct. Moreover, with advances in technology and surgical skills, the use of laparoscopic transcystic common bile duct exploration (LTCBDE) is gradually rising.

OBJECTIVES

To compare the safety, feasibility, and short-term clinical benefits of LTCBDE and LCBDE through matched cases.

METHODS

Web of science, Cochrane, PubMed, and CNKI were searched systematically to identify studies published between January 2007 and December 2017 that compared LTCBDE and LCBDE without a restriction of languages. This meta-analysis was performed using Review Manager 5.3.

RESULTS

Twenty-one studies matched the selection criteria, including 1561 cases of LTCBDE and 1500 cases of LCBDE. There was no obvious difference in stone clearance (OR 1.44, 95% CI 0.84-2.47; P = 0.18). However, LTCBDE had a shorter operative time (MD - 17.72, 95% CI - 19.42 to - 16.02; P < 0.00001) and shorter hospital stay (MD - 2.20, 95% CI - 2.32 to - 2.08; P < 0.00001). Besides, the LTCBDE group showed significantly better results for blood loss (MD - 7.61, 95% CI - 8.85 to - 6.37; P < 0.00001) and postoperative complications (OR 0.28, 95% CI 0.19-0.41; P < 0.00001). In addition, LTCBDE was more cost efficient (MD - 2.51, 95% CI - 2.72 to - 2.30; P < 0.00001). Further, we calculated the absolute mean of operative time (LTCBDE:LCBDE = 97.56:117.81 min), hospital stay (LTCBDE:LCBDE = 5.22:8.91 days), hospital expenses (LTCBDE:LCBDE = 8646.121:11848.31 RMB), blood loss (LTCBDE:LCBDE = 29.3:52.0 ml), the rate of CBD stone clearance (LTCBDE:LCBDE = 92.8:95.0%), and postoperative complications (LTCBDE:LCBDE = 6.7:14.6%) in both groups to obtain more convincing results.

CONCLUSIONS

The stone clearance of LTCBDE was equal to that of LCBDE, and LTCBDE demonstrated a shorter operative time, lower blood loss, and other advantages. Thus, the surgical procedure of laparoscopic transcystic choledochotomy is feasible and safe.

The safety and feasibility of laparoscopic common bile duct exploration for treatment patients with previous abdominal surgery

The purpose of this study was to evaluate the safety and feasibility of laparoscopic common bile duct exploration (LCBDE) in patients with previous abdominal surgery (PAS). The outcomes were compared in 139 patients (103 upper and 36 lower abdominal surgeries) with PAS and 361 without PAS who underwent LCBDE. The operative time, hospital stay, rate of open conversion, postoperative complications, duct clearance, and blood loss were compared. Patients with PAS had longer operative times (P = 0.006), higher hospital costs (P = 0.043), and a higher incidence of wound complications (P = 0.011) than those without PAS. However, there were no statistically significant in the open conversion rate, blood loss, hospital stay, bile leakage, biliary strictures, residual stones, and mortality between patients with and without PAS (P > 0.05). Moreover, compared with those without PAS, patients with previous upper abdominal surgery (PUAS) had longer operative times (P = 0.005), higher hospital costs (P = 0.030), and a higher open conversion rate (P = 0.043), but patients with previous lower abdominal surgery (PLAS) had a higher incidence of wound complications (P  = 0.022). LCBDE is considered safe and feasible for patients with PAS, including those with PUAS.