Laparoscopic common bile duct exploration for elderly patients: as a first treatment strategy for common bile duct stones

Comparison of laparoscopic common bile duct exploration plus cholecystectomy and endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy for elderly patients with common bile duct stones and gallbladder stones

BACKGROUND

Common bile duct (CBD) stones commonly occur in cholecystectomy cases. The management options include laparoscopic CBD exploration (LCBDE) or endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). Although ERCP is fully developed, it has complications, and LCBDE is a proven alternative. This study aimed to evaluate the safety and efficacy of these treatments in elderly individuals aged ≥70 years.

METHODS

A retrospective study between January 2015 and July 2022 included 160 elderly patients (aged ≥70 years) diagnosed with cholelithiasis and choledocholithiasis. The patients were divided into 1-stage (LCBDE [n = 80]) or 2-stage (ERCP followed by LC [n = 80]) treatment groups. Data collected encompassed comorbidities, symptoms, bile duct clearance, postoperative complications, and long-term outcomes for systematic analysis.

RESULTS

This study analyzed 160 patients treated for CBD stones, comparing 1-stage and 2-stage groups. The 1-stage group had more female patients than the 2-stage group (57.5% vs 37.5%, respectively). The 1-stage group had a mean age of 80.55 ± 7.00 years, which was higher than the mean age in the 2-stage group. American Society of Anesthesiologists classification, Charlson Comorbidity Index, and laboratory findings were similar. Pancreatitis and cholangitis occurred after ERCP in the 2-stage group. Stone clearance rates (92.35% [1-stage group] vs 95.00% [2-stage group]) and biliary leakage incidence (7.5% [1-stage group] vs 3.0% [2-stage group]) were similar, as were postoperative complications and long-term recurrence rates (13.0% [1-stage group] vs 12.5% [2-stage group]).

CONCLUSION

Our research indicates that both the combination of LCBDE and LC and the sequence of ERCP followed by LC are equally efficient and secure when treating CBD stones in elderly patients. Consequently, the 1-stage procedure may be considered the preferred treatment approach for this demographic.

Curative surgical treatment of common bile duct stones: Retrospective cohort study

BACKGROUND

In the event of symptomatic common bile duct (CBD) stones with dilated CBD, one possible curative treatment option is stone extraction through choledocotomy associated with cholecystectomy. Endoscopic treatment is only reserved for residual stones at 6 weeks. The aim of this study was to evaluate the results from laparoscopic curative surgical treatment of CBD stones with dilated CBD.

METHODS

This is a retrospective single-centered cohort study. All consecutive patients admitted for laparoscopic cholecystectomy with evidence of CBD stones with dilated CBD from January 2010 to December 2020 at our center were included. Success was defined by CBD clearance at 6 weeks. Need for additional procedures, such as endoscopic sphincterotomy, immediate, and end-of-procedure morbi-mortality as well as factors associated with procedure failure, were also studied.

RESULTS

A total of 246 patients who received curative treatment were included in the study. The success rate for the curative treatment was 93.1% (229 patients). Immediate postoperative morbidity was 24.4% with a 5.3% reintervention rate. Immediate and 6-week postoperative mortality rates were zero and 0.4%, respectively. The mean length of stay was 11.3 days. Factors associated with procedure failure appeared to be the occurrence of an early postoperative complication and the need for readmission during the period between surgery and drain removal.

CONCLUSION

This study indicates that laparoscopic curative surgical treatment for symptomatic CBD stones may be performed with acceptable results without routine need for additional procedures.

Outcomes following common bile duct exploration versus endoscopic stone extraction before, during and after laparoscopic cholecystectomy for patients with common bile duct stones

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) and endoscopic retrograde cholangiopancreatography (ERCP) are two methods of retrieving common bile duct (CBD) stones. The best method for CBD stone removal is debatable. The aim of this study was to compare outcomes following LCBDE and/or ERCP, including laparoscopic cholecystectomy.

METHODS

Data were collected retrospectively for patients undergoing LCBDE and/or ERCP at a single centre from 2008 to 2018. Patients were grouped by intention-to-treat (single-stage LCBDE, pre-operative-, intra-operative-, or post-operative ERCP) and eventual plan (surgical or endoscopic). Outcomes included complication rates (minor Clavien-Dindo 1/2, major Clavien-Dindo 3/4, non-biliary complications) and mortality.

RESULTS

Of 671 patients, 578 patients received LCBDE and 93 patients received ERCP as primary care. Endoscopic clearance had significantly higher complications and mortality compared to surgical clearance. On an intention-to-treat basis LCBDE had the lowest minor-, major- and non-biliary complications, and mortality (5.2%, 6.1%, 2.9% and 0.5%, respectively), whilst pre-operative ERCP the worst (39.6%, 27.1%, 29.2% and 8.3%, respectively) (p=<0.001). LCBDE and postERCP had similar major complications and mortality.

CONCLUSION

Surgical clearance of CBD stones was potentially safer than endoscopic clearance. Pre-operative ERCP had the worst outcomes. LCBDE and postERCP are likely to have similar short-term patient outcomes.

Contemporary management of concomitant gallstones and common bile duct stones: a survey of Spanish surgeons

BACKGROUND

Concomitant gallstones and common bile duct stones (CBDS) is a relatively frequent presentation. The optimal treatment remains controversial and the debate persists between two strategies. The one-stage approach: laparoscopic cholecystectomy with laparoscopic common bile duct exploration (LCBDE) has been shown to be equally safe and more cost-effective than the more traditional two-stage approach: endoscopic retrograde cholangiography followed by laparoscopic cholecystectomy (ERCP + LC). However, many surgeons worldwide still prefer the two-stage procedure. This survey evaluated contemporary management of CBDS in Spain and assessed the impact of surgeon and hospital factors on provision of LCBDE.

METHODS

A 25-item, web-based anonymous survey was sent to general surgeons members of the Spanish Surgeons Association. Descriptive statistics were applied to summarize results.

RESULTS

Responses from 305 surgeons across 173 Spanish hospitals were analyzed. ERCP is the initial approach for preoperatively suspected CBDS for 86% of surgeons. LCBDE is the preferred method for only 11% of surgeons and only 11% treat more than 10 cases per year. For CBDS discovered intraoperatively, 59% of respondents attempt extraction while 32% defer to a postoperative ERCP. The main reasons cited for not performing LCBDE were lack of equipment, training and timely availability of an ERCP proceduralist. Despite these barriers, most surgeons (84%) responded that LCBDE should be implemented in their departments.

CONCLUSIONS

ERCP was the preferred approach for CBDS for the majority of respondents. There remains limited use of LCBDE despite many surgeons indicating it should be implemented. Focused planning and resourcing of both training and operational demands are required to facilitate adoption of LCBDE as option for patients.

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.

Laparoscopic common bile duct exploration for elderly patients with choledocholithiasis: a systematic review and meta-analysis

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) has been becoming more and more popular in patients with symptomatic choledocholithiasis. However, the safety and effectiveness of LCBDE in elderly patients with choledocholithiasis is still uncertain. This meta-analysis is aimed to appraise the safety and feasibility of LCBDE for elderly patients with choledocholithiasis.

MATERIALS AND METHODS

Studies comparing elderly patients and younger patients who underwent LCBDE for common bile duct stone were reviewed and collected from the PubMed, Medline, EMBASE, and Cochrane Library. Primary outcomes were stone clearance rate, overall complication rate, and mortality rate. Secondary outcomes were operative time, conversion rate, pulmonary complication, bile leakage, reoperation, residual stone rate, and recurrent stone rate.

RESULTS

Nine studies, including two prospective studies and seven retrospective studies, met the inclusion criteria. There were 2004 patients in this meta-analysis, including 693 elderly patients and 1311 younger patients. There was no statistically significant difference between elderly patients and younger patients regarding stone clearance rate (OR 0.73; 95% CI 0.42-1.26; p = 0.25), overall complication rate (OR 1.31; 95% CI 0.94-1.82; p = 0.12), and mortality rate (OR 2.80; 95% CI 0.82-9.53; p = 0.10). Similarly, the operative time, conversion rate, bile leakage, reoperation, residual stone rate, and recurrent stone rate showed no significant difference between two groups (p > 0.05). While elderly patients showed high risk for pulmonary complication (OR 4.41; 95% CI 1.78-10.93; p = 0.001) compared with younger patients.

CONCLUSION

Although there is associated with higher pulmonary complication, LCBDE is still considered as a safe and effective treatment for elderly patients with choledocholithiasis.

Laparoscopic common bile duct exploration with primary closure is safe for management of choledocholithiasis in elderly patients

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) is one of the minimally invasive options for choledocholithiasis. Primary closure of the common bile duct (CBD) upon completion of laparoscopic choledochotomy is safe in selected patients. The present study aimed to evaluate the feasibility and safety of primary closure of CBD after LCBDE in patients aged 70 years or older.

METHODS

A total of 116 patients (51 males and 65 females) who suffered from choledocholithiasis and underwent primary closure of the CBD (without T-tube drainage) after LCBDE from January 2003 to December 2017 were recruited. They were classified into two groups according to age: group A (≥70 years, n = 56), and group B (<70 years, n = 60). The preoperative characteristics, intraoperative details, and postoperative outcomes of the two groups were evaluated.

RESULTS

The mean operative time was 172.02 min for group A and 169.92 min for group B (P = 0.853). The mean hospital stay was 7.40 days for group A and 5.38 days for group B (P < 0.001). Bile leakage occurred in two patients in group A and one in group B (3.57% vs 1.67%, P = 0.952). There were no significant differences in the rates of postoperative complications and mortality between the two groups. At median follow-up time of 60 months, stone recurrence was detected in one patient in group A and two in group B (1.79% vs 3.33%, P = 1.000). Stenosis of CBD was not observed in group A and slight stenosis in one patient in group B (0 vs 1.67%, P = 1.000).

CONCLUSION

Primary closure of the CBD upon completion of laparoscopic choledochotomy is safe and feasible in elderly patients ≥70 years old.

Clinical Efficacy Analysis of the Combination of the Laparoscope and Preoperative or Intraoperative Duodenoscope in the Treatment of Cholecystolithiasis with Choledocholithiasis: A Retrospective Study

Aim: This study aims to analyze the efficacy and safety of the combination of laparoscope and preoperative (PODL) or intraoperative (IODL) duodenoscope in the treatment of cholecystolithiasis with choledocholithiasis.

Materials and Methods: From January 2015 to February 2017, 51 patients with cholecystolithiasis and choledocholithiasis, who were treated with the PODL (n = 29) or IODL (n = 22), were reviewed retrospectively. The efficacy and safety were evaluated and compared between these two groups.

Results: The success rates were 100% in IODL group and 96.6% in PODL group. There was no statistical significance in the difference of stone clearance rate and residual stone rate between two groups (P > .05). There were no significant differences in complications, like aspiration, gastrointestinal perforation, and acute cholangitis between two groups (P > .05). IODL significantly decreased numeric rating scale (NRS) scoring, reduced surgery cost and shortened hospitalization time compared to that of PODL group (P < .05). No cholangitis, reoccurrence of stones or biliary obstruction occurred in all 51 patients.

Conclusion: In this retrospective study, IODL was found superior to PODL. And the IODL can significantly decrease NRS scoring, reduce surgery cost and shorten hospitalization time.

Prevalence and Predictors of Unnecessary Endoscopic Retrograde Cholangiopancreatography in the Two-Stage Endoscopic Stone Extraction Followed by Laparoscopic Cholecystectomy

BACKGROUNDS

A two-stage procedure involving endoscopic retrograde cholangiopancreatography (ERCP), followed by cholecystectomy, is one of the primary treatments of concomitant gallstones and choledocholithiasis. However, negative findings on ERCP and migrating gallstones after cholecystectomy are major concerns. This study aimed to identify the prevalence of unnecessary ERCP and to develop and validate a predictive nomogram using preoperative factors in patients who underwent a two-stage procedure.

METHODS

Consecutive 931 patients were treated with the two-stage procedure for evident gallstones and suspected choledocholithiasis. After the cholecystectomy, a cholangiogram was performed to confirm the absence of the migrating gallstones. The patients were divided into derivation (n = 652) and validation (n = 279) cohorts.

RESULTS

A total of 26.5% (247/931) patients had unnecessary ERCP (negative choledocholithiasis, 14.6%; migrating gallstones, 11.9%). No stones on images (P < 0.001), total bilirubin < 1.2 mg/dL (P = 0.006), and common bile duct diameter < 8.0 mm (P = 0.004) were independent factors associated with negative finding on ERCP with a validated nomogram area under the curve (AUC) of 0.72 (95% confidence interval [CI] 0.64-0.80). For migrating gallstones after cholecystectomy, radiolucent gallstones (P < 0.001), gallstone size ≤ 6.4 mm (P = 0.001), cystic duct stones (P < 0.001), gallbladder wall thickness ≥ 3.2 mm (P = 0.003), and low-lying cystic duct (P < 0.001) were independent factors with a validated nomogram AUC of 0.77 (95% CI 0.68-0.87).

CONCLUSIONS

About one fourth of the patients may have unnecessary ERCP in the two-stage procedure. Based on our nomogram using preoperative factors, high-risk patients who are more likely to perform unnecessary ERCP could be considered for the one-stage procedure.

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.

Advantages of laparoscopic common bile duct exploration in common bile duct stones

OBJECTIVE

To compare the efficacy, safety, and surgical outcomes of laparoscopic common bile duct exploration, endoscopic retrograde cholangiopancreatography, and open common bile duct exploration for treatment of common bile duct stones.

METHODS

In total, 210 patients were prospectively randomized into 3 groups: laparoscopic common bile duct exploration, endoscopic retrograde cholangiopancreatography, and open common bile duct exploration. The primary outcome measures were the common bile duct stone clearance rate and the complication rate. The secondary outcome measures were mortality, total costs, and length of hospital stay.

RESULTS

The success rates in the laparoscopic common bile duct exploration group (97.14%, 68 out of 70) and open common bile duct exploration group (98.57%, 69/70) were significantly higher than that in the endoscopic retrograde cholangiopancreatography group (85.71%, 60/70, both p < 0.05). The complication rates in the laparoscopic common bile duct exploration group (2.86%, 2/70) and open common bile duct exploration group (1.43%, 1/70) were significantly lower than that in the endoscopic retrograde cholangiopancreatography group (14.29%, 10/70, both p < 0.05). The success rate and complication rate were not significantly different between the laparoscopic common bile duct exploration group and open common bile duct exploration group (both p > 0.05).

CONCLUSION

Laparoscopic common bile duct exploration provides an alternative therapeutic approach that was safer and more reliable, allowed for earlier recovery, and provided more cost-effective treatment of common bile duct stones.

Laparoscopic common bile duct exploration: a safe and definitive treatment for elderly patients

BACKGROUND

Common bile duct (CBD) stone is one of the most common diseases among elderly people. In recent decades, there are numerous studies regarding the safety and efficacy of laparoscopic common bile duct exploration (LCBDE). Elderly patients are often regarded as high-risk patients because they are more likely to present with age-specific deterioration of organ function and coexisting chronic diseases, which may reduce their tolerance of laparoscopic surgery. Although laparoscopic surgery for choledocholithiasis is now widely accepted as the treatment for CBD stone, its appropriateness for the treatment of elderly patients or those with coexisting high-risk patients has not been well established. Therefore, the objective of this paper is to analyze the safety and efficacy of LCBDE in elderly patients.

METHODS

Between January 2012 and November 2015, 376 patients underwent LCBDE in our center. Based on their ages, they were divided into two groups, and a retrospective study was performed. By making comparisons between younger group who were younger than 70 years (n = 253) and elderly group who were 70 years old or older (n = 123), the demographics, clinical characteristics, laboratory data, operative parameters and outcomes were analyzed.

RESULTS

Before operation, elderly patients had more coexisting chronic diseases and risk factors, such as arterial hypertension, heart diseases, pulmonary diseases and previous abdominal surgery (P < 0.05). In both groups, LCBDE was equally successful with a high clearance rate (100 % in elderly patients vs. 98.8 % in younger group, P = 0.554). Besides, the operating time, intraoperative blood loss, postoperative hospital stay, total costs and overall complication showed no significant difference between two groups (P > 0.05). There was no major bile duct injury or death in either group.

CONCLUSION

Although elderly patients are frequently confronted with coexisting disorders, LCBDE can be considered as a safe and effective technique in choledocholithiasis treatment for elderly patients.

Micro-Incision of the Cystic Duct Confluence in Laparoscopic Common Bile Duct Exploration for Elderly Patients with Choledocholithiasis

Common bile duct (CBD) stones are common in elderly patients. The laparoscopic transcystic approach with micro-incision of the cystic duct confluence in common bile duct exploration (LTM-CBDE) is a modified laparoscopic transcystic approach. Its safety and efficacy have not been studied in elderly patients with secondary choledocholithiasis. This study evaluates the safety and efficacy of LTM-CBDE in elderly (≥65 years) patients with secondary choledocholithiasis and compares the results with those in younger patients. In this retrospective analysis, 128 patients underwent LTM-CBDE from March 2007 to December 2013. The patients were divided into two groups according to age: the elderly group consisted of 50 patients aged ≥65 years and the younger group consisted of 78 patients aged <65 years. The preoperative morbidity rate, American Society of Anesthesiologists (ASA) score, previous abdominal operations, operation time, postoperative hospital stay, open conversion rate, postoperative complication rate, residual stone rate, recurrence rate and mortality were compared in both groups. The preoperative morbidity (41 vs. 28) and ASA score (2.5 ± 0.7 vs. 1.8 ± 0.6) were higher in the elderly group (P = 0.000, in both groups). No significant differences in previous abdominal operations, operation time, postoperative hospital stay, open conversion rate, postoperative complication rate, residual stone rate, recurrence rate and mortality (P > 0.05) were found between the two groups from March 2007 to December 2013. LTM-CBDE is a safe and effective treatment procedure for elderly patients with secondary choledocholithiasis. For suitable patients, we recommend LTM-CBDE as the treatment of choice.

Laparoscopic Transcystic Common Bile Duct Exploration in the Elderly is as Effective and Safe as in Younger Patients

BACKGROUND

Choledocholithiasis represents a greater proportion of gallstone in the elderly. Elderly patients have more comorbidity, which could increase the operative risk and postoperative complications. However, no study has focused on the effect and safety of laparoscopic transcystic common bile duct exploration (LTCBDE) in elderly patients. The aim of this study was to investigate whether LTCBDE can be performed effectively and safely in elderly patients.

METHODS

This is a retrospective study of patients who underwent LTCBDE for choledocholithiasis performed from January 2010 to December 2012. Patients of age 70 or older were included in the elderly group. The rest integrated the younger group. Demographic data and perioperative parameters were compared between groups.

RESULTS

From January 2010 to December 2012, 171 patients admitted for choledocholithiasis and gallstone attempted a single-step treatment combining LTCBDE and laparoscopic cholecystectomy. There were 104 women (60.8%) and 67 men (39.2%) with a median age of 57 (range 24-87) years. Elderly patients had significantly more preoperative risk factors. However, there was no significant difference in the success rate of LTCBDE (96.9% versus 92.7%, P = .142) for the two groups. The operative time was a little longer in elderly group than in younger group: median 80 (60-110) minutes versus 70 (50-95) minutes, respectively (P < .001). Postoperative recovery was slower in elderly group than in younger group, as reflected by a longer median postoperative hospital stay (2 days versus 1 day, P < .001) and a higher rate of abdominal drain placed (17.1% versus 8.5%, P = .202). The rates of postoperative complications at discharge were similar between groups (3.0% versus 4.9%, P = .952).

CONCLUSION

LTCBDE in the elderly patients is as effective and safe as in younger patients.

Clinical effects of laparoscopic common bile duct exploration and T-tube drainage in elderly patients with a history of upper abdominal operation

AIM: To assess the feasibility, effectiveness, and safety of laparoscopic common bile duct exploration and T-tube drainage (LCBDE-TD) in elderly patients with a history of upper abdominal operation, and summarize the surgical methods and skills.

METHODS: The clinical data for 28 elderly patients (>60 years) with a history of upper abdominal operation from January 2012 to December 2013 were retrospectively analyzed. Of these patients, 15 underwent LCBDE-TD and 13 underwent open common bile duct exploration and T-tube drainage (OCBDE-TD). The average time of operation, intro-operative blood loss, time to recovery of gastrointestinal function and postoperative hospitalization time were compared between the two groups.

RESULTS: All the patients were operated successfully. The operative time for the laparoscopy group and open group was, respectively, 120.4 min ± 40.6 min and 164.4 min ± 47.9 min (P = 0.014 < 0.05). The intro-operative blood loss was 62.0 mL ± 33.4 mL and 110.8 mL ± 52.8 mL, respectively (P = 0.006 < 0.05). The time to postoperative recovery of gastrointestinal function was 3.9 d ± 1.0 d and 4.9 d ± 1.1 d, respectively (P = 0.022 < 0.05). The postoperative hospitalization time was 8.5 d ± 2.2 d and 13.4 d ± 5.0 d, respectively (P = 0.002 < 0.05).

CONCLUSION: LCBDE-TD for elderly patients with a history of upper abdominal operation has the advantages of shorter operative time, less intra-operative blood loss, faster recovery of gastrointestinal function, and shorter hospitalization than open surgery.

Gallstone pancreatitis: a review

Gallstone disease is the most common cause of acute pancreatitis in the Western world. In most cases, gallstone pancreatitis is a mild and self-limiting disease, and patients may proceed without complications to cholecystectomy to prevent future recurrence. Severe disease occurs in about 20% of cases and is associated with significant mortality; meticulous management is critical. A thorough understanding of the disease process, diagnosis, severity stratification, and principles of management is essential to the appropriate care of patients presenting with this disease. This article reviews these topics with a focus on surgical management, including appropriate timing and choice of interventions.

Comparison of laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for choledocholithiasis: a prospective randomized study

BACKGROUND

Endoscopic retrograde cholangiopancreatography and laparoscopic common bile duct exploration are safe and efficient methods that have recently been used for the treatment of bile duct stones. The aim of this study was to compare the efficacy, safety, and surgical outcomes of the laparoscopic common bile duct exploration plus laparoscopic cholecystectomy (LCBDE+LC) and endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy (ERCP+LC).

METHODS

One hundred twenty patients were prospectively randomized into 2 groups: LCBDE with LC in a single intervention and LC after ERCP.

RESULTS

The success rate of the LCBDE+LC group (96.5%) was found to be higher than for the ERCP+LC group (94.4%). Complication rates of the LCBDE+LC and ERCP+LC group were 7% and 11.1%, respectively. Complications requiring ERCP in the postoperative period after LCBDE+LC have been noted in 3.5% of cases.

CONCLUSIONS

Laparoscopic CBD exploration provides an alternative therapeutic approach that has less morbidity, is cost-effective, and allows earlier recovery with a reduced period of short-term disability.

Minimally invasive phasic treatment protocol for the treatment of extrahepatic bile duct stones

OBJECTIVES

To identify the optimal treatment for extrahepatic bile duct stones using endoscopy, laparoscopy, and the combination of the two in different conditions and to develop phasic treatment protocols for their minimally invasive treatment.

PATIENTS AND METHODS

Of 2718 cases of extrahepatic bile duct stones collected from June 2005 to December 2011, 50 were randomly selected to receive open bile duct exploration and T-tube drainage, serving as the control group. For the rest, a one-scope protocol, two-scope protocol (two-scope protocol A or two-scope protocol B), or three-scope protocol was adopted according to the specific conditions of stones and the endoscopic treatment results. The treatment outcomes and postoperative clinical indicators of the minimally invasive treatment protocols were analyzed and compared with those of the control group.

RESULTS

Among the 2668 cases of extrahepatic bile duct stones receiving the phasic minimally invasive treatment, the treatment success rate was 97.79%, and there were no severe postoperative complications. Compared with the control group, the minimally invasive treatment protocols had higher success rates, less trauma, and significantly shortened hospital stays.

CONCLUSIONS

The protocols were applied step by step based on the different types and levels of extrahepatic bile duct stones, fully embodying the advantages of the combined minimally invasive treatment of endoscopy and laparoscopy, thus expanding the scope of minimally invasive surgical treatment for extrahepatic bile duct stones and improving treatment success rate.

Therapeutic value of laparoscopy combined with choledochoscopy for common bile duct stones: An analysis of 107 cases

AIM: To explore the value of laparoscopy combined with choledochoscopy in the treatment of common bile duct stones.

METHODS: The clinical data for 107 patients with choledochlithiasis who underwent laparoscopic common bile duct exploration and stone removal with choledochosopy from April 2008 to March 2011 at our hospital was retrospectively analyzed to explore their therapeutic value.

RESULTS: Of 107 patients, 102 had successful laparoscopy and choledochoscopy, and 5 underwent a conversion to laparotomy. Total operative time was 120-150 min (average 140 min). Blood loss was 20-80 mL (average 55 mL). Postoperative hospitalization length was 7-15 d (average 8. 5 d). Peritoneal drainage tubes were placed in 83 cases; 16 cases only had little pale yellow drainage fluid on the first postoperative day, and their tubes were removed on the fourth postoperative day after no fluid was drained for 3 d. About 300 mL of fluid was drained on the first postoperative day in the remaining patients, and their tubes were removed on the sixth postoperative day after no fluid was drained for 4 d. T-tubes were removed 4 wk postoperatively. All of the patients recovered well and were followed up for 3 to 6 months. No patients developed bile leakage, residual stones, or bile duct stricture.

CONCLUSION: Laparoscopy combined with choledochoscopy has good efficacy and fewer complications and is less invasive in the management of common bile duct stones.