Thirteen years' experience with laparoscopic transcystic common bile duct exploration for stones. Effectiveness and long-term results

Diagnostic performance of laparoscopic transcystic common bile duct exploration for the detection of choledocholithiasis in patients with negative MRCP

There is little research to evaluate laparoscopic transcystic common bile duct (CBD) exploration (LTCBDE) as a diagnostic test to identify choledocholithiasis undergoing laparoscopic cholecystectomy (LC). This study aimed to assess the technical success and safety of LTCBDE in patients with suspected choledocholithiasis but negative magnetic resonance cholangiopancreatography (MRCP) undergoing LC. We did an ambispective cohort study in patients with gallstones and suspected CBD stones but negative MRCP undergoing LC. The primary outcomes were the rate of complications in the hospital. Between January 2010 and December 2018, 620 patients (median age, 58 years; 58.4% female) were eligible for the study. The success rate of LTCBDE was 91.8% and CBD stones were observed in 53.3% with a stone clearance rate of 99.3%. The overall postoperative complication rate was 0.65% and no death was recorded in the total cohort. Notably, the morbidity in LTCBDE is 0.53%. Retained CBD stones were diagnosed in 2 patients and managed by ERCP successfully. In the LTCBDE cohort, the median duration of operation was 78 (60-100) min and the median postoperative hospital stay was 1 (1-2) days. Overall, at a mean follow-up of 4.1 (2.3-6.1) years, recurrent CBD stones occurred in 1.1% and all-cause mortality in 0.6%. LTCBDE should be considered the favored choice in the diagnostic algorithm for patients with suspected choledocholithiasis but negative MRCP undergoing LC.

Evidence-based clinical practice guidelines for cholelithiasis 2021

The Japanese Society of Gastroenterology first published evidence-based clinical practice guidelines for cholelithiasis in 2010, followed by a revision in 2016. Currently, the revised third edition was published to reflect recent evidence on the diagnosis, treatment, and prognosis of cholelithiasis conforming to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Following this revision, the present English version of the guidelines was updated and published herein. The clinical questions (CQ) in the previous version were reviewed and rearranged into three newly divided categories: background questions (BQ) dealing with basic background knowledge, CQ, and future research questions (FRQ), which refer to issues that require further accumulation of evidence. Finally, 52 questions (29 BQs, 19 CQs, and 4 FRQs) were adopted to cover the epidemiology, pathogenesis, diagnosis, treatment, complications, and prognosis. Based on a literature search using MEDLINE, Cochrane Library, and Igaku Chuo Zasshi databases for the period between 1983 and August 2019, along with a manual search of new information reported over the past 5 years, the level of evidence was evaluated for each CQ. The strengths of recommendations were determined using the Delphi method by the committee members considering the body of evidence, including benefits and harms, patient preference, and cost-benefit balance. A comprehensive flowchart was prepared for the diagnosis and treatment of gallbladder stones, common bile duct stones, and intrahepatic stones, respectively. The current revised guidelines are expected to be of great assistance to gastroenterologists and general physicians in making decisions on contemporary clinical management for cholelithiasis patients.

Laparoscopic transcystic common bile duct exploration versus transgastric endoscopic retrograde cholangiography during cholecystectomy after Roux-en-Y gastric bypass

BACKGROUND

Treatment of common bile duct (CBD) stones after Roux-en-Y gastric bypass (RYGB) poses a particular challenge given the altered anatomy and inability to perform a standard endoscopic retrograde cholangiogram (ERC). The optimal treatment strategy for intraoperatively encountered CBD stones in post-RYGB patients has not been established.

OBJECTIVES

To compare outcomes following laparoscopic transcystic common bile duct exploration (LTCBDE) and laparoscopy-assisted transgastric ERC for CBDs during cholecystectomy in RYGB-operated patients.

SETTING

Swedish nationwide multi-registry study.

METHODS

The Swedish Registry for Gallstone Surgery and ERCs, GallRiks (n = 215,670), and the Scandinavian Obesity Surgery Registry (SOReg) (n = 60,479) were cross-matched for cholecystectomies with intraoperatively encountered CBD stones in patients with previous RYGB surgery between 2011 and 2020.

RESULTS

Registry cross-matching found 550 patients. Both LTCBDE (n = 132) and transgastric ERC (n = 145) were comparable in terms of low rates of intraoperative adverse events (1% versus 2%) and postoperative adverse events within 30 days (16% versus 18%). LTCBDE required significantly shorter operating time (P = .005) by on average 31 minutes, 95% confidence interval (CI) [10.3-52.6], and was more often used for smaller stones <4 mm in size (30% versus 17%, P = .010). However, transgastric ERC was more often used in acute surgery (78% versus 63%, P = .006) and for larger stones >8 mm in size (25% versus 8%, P < .001).

CONCLUSIONS

LTCBDE and transgastric ERC have similarly low complication rates for clearance of intraoperatively encountered CBD stones in RYGB-operated patients, but LTCBDE is faster while transgastric ERC is more often used in conjunction with larger bile duct stones.

Long-term mortality and intestinal obstruction after laparoscopic cholecystectomy: A systematic review and meta-analysis

BACKGROUND

Long-term outcomes of cholecystectomy are largely unknown though it is a common procedure in general surgery. We aimed to investigate the long-term mortality rate and incidence of intestinal obstruction after laparoscopic cholecystectomy.

MATERIALS AND METHODS

This systematic review and meta-analysis was reported according to the PRISMA 2020 and AMSTAR guidelines. A protocol was registered on PROSPERO (CRD42020178906). The databases PubMed, EMBASE, and Cochrane CENTRAL were last searched on February 9, 2022 for original studies on long-term complications with n > 40 and follow-up ≥ 6 months. Outcomes were long-term mortality and incidence of intestinal obstruction, and meta-analyses were conducted. Risk of bias was assessed with Newcastle-Ottawa Scale and Cochrane "Risk of bias"-tool according to study design.

RESULTS

We included 41 studies that reported long-term follow-up on 1,000,534 patients. Of these, 38 studies reported on mortality (514,242 patients) that ranged from 0 to 32%. Meta-analysis estimated a long-term mortality rate of 2.0% (95% CI 1.7-2.3%) after laparoscopic cholecystectomy. Five studies including 486,292 patients reported on intestinal obstruction that ranged from 0 to 6%. Meta-analysis estimated a long-term rate of intestinal obstruction of 1.3% (95% CI 0.8-1.8%).

CONCLUSION

Long-term mortality after laparoscopic cholecystectomy was 2%. The incidence of long-term intestinal obstruction after laparoscopic cholecystectomy was 1.3%.

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.

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.

Systematic Review and Meta-analysis of Laparoscopic Common Bile Duct Exploration in Patients With Previous Failed Endoscopic Retrograde Cholangiopancreatography

BACKGROUND

The aim was to compare the outcomes of laparoscopic common bile duct exploration (LCBDE) after failed endoscopic retrograde cholangiopancreatography (group A) versus primary LCBDE (group B) for the management of gallbladder and common bile duct stones.

MATERIALS AND METHODS

A comprehensive and systematic literature search was performed in several databases, including PubMed, Ovid, and Cochrane Library. Meta-analysis of operative outcomes, postoperative outcomes, and gallstone clearance rates was conducted using random-effect models.

RESULTS

Six studies including 642 patients (239 in group A and 403 in group B) were included. The operative time was longer in group A (P=0.02). The overall complication, bile leakage, conversion, postoperative hospital stay, and reoperation were comparable in group A and group B. Similarly, no significant difference was present concerning the incidence of stone clearance, residual stone, and recurrent stone (P>0.05).

CONCLUSION

LCBDE is an alternative acceptable procedure when removal of common bile duct stones by endoscopic therapy fails.

One-stage fluoroscopy-guided laparoscopic transcystic papillary balloon dilation and laparoscopic cholecystectomy in patients with cholecystocholedocholithiasis who previously had undergone gastrectomy for gastric cancer

BACKGROUND

Patients with a history of gastrectomy have a higher incidence of cholecystocholedocholithiasis (CCL) and related morbidities than the general population. However, the management of common bile duct (CBD) stones with endoscopic retrograde cholangiopancreatography is challenging in patients after Roux-en-Y or Billroth II reconstruction because of the altered gastrointestinal anatomy. The aim of the current study was to evaluate the safety and efficacy of one-stage laparoscopic transcystic papillary balloon dilation and laparoscopic cholecystectomy (LTPBD+LC) in patients with previous gastrectomy for gastric cancer.

METHODS

This retrospective cohort study included five patients with CCL who had previously undergone gastrectomy. All five underwent LTPBD+LC between May 2015 and February 2020 at our institution. The primary end-point was complete clearance of the CBD stones.

RESULTS

Of the 311 patients who had undergone gastrectomy for gastric cancer from December 2009 to December 2018 at our institution, six (1.9%) were later diagnosed with CCL. Five of the six patients did not need emergency biliary drainage and underwent conservative therapy and subsequent elective LTPBD+LC. LTPBD+LC was successfully performed in all cases. None of the patients required conversion to open surgery. The rate of complete clearance of the CBD stones was 100%. The mean operative time of the entire procedure was 126 minutes (range, 102-144 minutes), and the mean blood loss was 12.4 mL (range, 1-50 mL). There were no major perioperative complications, and the mean length of postoperative hospital stay was 4.2 days (range, 3-7 days).

CONCLUSION

One-stage LTPBD+LC may be a feasible procedure for patients with CCL who have previously undergone gastrectomy for gastric cancer.

Postoperative rendezvous endoscopic retrograde cholangiopancreaticography as an option in the management of choledocholithiasis

BACKGROUND

Rendezvous endoscopic retrograde cholangiopancreaticography (ERCP) is a well-established method for treatment of choledocholithiasis. The primary aim of this study was to determine how different techniques for management of common bile duct stone (CBDS) clearance in patients undergoing cholecystectomy have changed over time at tertiary referral hospitals (TRH) and county/community hospitals (CH). The secondary aim was to see if postoperative rendezvous ERCP is a safe, effective and feasible alternative to intraoperative rendezvous ERCP in the management of CBDS.

METHODS

Data were retrieved from the Swedish registry for cholecystectomy and ERCP (GallRiks) 2006-2016. All cholecystectomies, where CBDS were found at intraoperative cholangiography, and with complete 30-day follow-up (n = 10,386) were identified. Data concerning intraoperative and postoperative complications, readmission and reoperation within 30 days were retrieved for patients where intraoperative ERCP (n = 2290) and preparation for postoperative ERCP were performed (n = 2283).

RESULTS

Intraoperative ERCP increased (7.5% 2006; 43.1% 2016) whereas preparation for postoperative ERCP decreased (21.2% 2006; 17.2% 2016) during 2006-2016. CBDS management differed between TRHs and CHs. Complications were higher in the postoperative rendezvous ERCP group: Odds Ratio [OR] 1.69 (95% confidence interval [CI] 1.16-2.45) for intraoperative complications and OR 1.50 (CI 1.29-1.75) for postoperative complications. Intraoperative bleeding OR 2.46 (CI 1.17-5.16), postoperative bile leakage OR 1.89 (CI 1.23-2.90) and postoperative infection with abscess OR 1.55 (CI 1.05-2.29) were higher in the postoperative group. Neither post-ERCP pancreatitis, postoperative bleeding, cholangitis, percutaneous drainage, antibiotic treatment, ICU stay, readmission/reoperation within 30 days nor 30-day mortality differed between groups.

CONCLUSIONS

Techniques for management of CBDS found at cholecystectomy have changed over time and differ between TRH and CH. Rendezvous ERCP is a safe and effective method. Even though intraoperative rendezvous ERCP is the preferred method, postoperative rendezvous ERCP constitutes an acceptable alternative where ERCP resources are lacking or limited.

One-stage fluoroscopic-guided laparoscopic transcystic papillary balloon dilation and laparoscopic cholecystectomy for the treatment of choledocholithiasis after Roux-en-Y reconstruction

Patients with a history of gastrectomy have a higher incidence of cholecystocholedocholithiasis and morbidities. In particular, the management of choledocholithiasis with endoscopic retrograde cholangiopancreatography (ERCP) has been challenging in patients after Roux-en-Y or Billroth II reconstruction due to the altered gastrointestinal anatomy. A 92-year-old man presented with high fever. He had undergone laparoscopic distal gastrectomy with Roux-en-Y reconstruction 9 years earlier for gastric cancer. Choledocholithiasis was diagnosed and ERCP was attempted, but cannulation of the papilla of Vater failed. An elective one-stage operation was planned. One-stage fluoroscopic-guided laparoscopic transcystic papillary balloon dilation (LTPBD) and laparoscopic cholecystectomy (LC) were performed. The operation time was 130 min with 3 mL of intraoperative bleeding. The patient was discharged on postoperative day 3 with no complications. We report this case in which one-stage LTPBD and LC was successfully performed for a super-elderly patient with choledocholithiasis after Roux-en-Y reconstruction.

Cardiovascular complications after common bile duct stone extractions

BACKGROUND

Common bile duct stone (CBDS) is a common condition the rate of which increases with age. Decision to treat in particular elderly and frail patients with CBDS is often complex and requires careful assessment of the risk for treatment-related cardiovascular complications. The aim of this study was to compare the rate of postoperative cardiovascular events in CBDS patients treated with the following: ERCP only; cholecystectomy only; cholecystectomy followed by delayed ERCP; cholecystectomy together with ERCP; or ERCP followed by delayed cholecystectomy.

METHODS

The study was based on data from procedures for gallstone disease registered in the Swedish National Quality Register for Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography (GallRiks) 2006-2014. ERCP and cholecystectomy procedures performed for confirmed or suspected CBDS were included. Postoperative events were registered by cross-matching GallRiks with the National Patient Register (NPR). A postoperative cardiovascular event was defined as an ICD-code in the discharge notes indicating myocardial infarct, pulmonary embolism or cerebrovascular disease within 30 days after surgery. In cases where a patient had undergone ERCP and cholecystectomy on separate occasions, the 30-day interval was timed from the first intervention.

RESULTS

A total of 23,591 underwent ERCP or cholecystectomy for CBDS during the study period. A postoperative cardiovascular event was registered in 164 patients and death within 30 days in 225 patients. In univariable analysis, adverse cardiovascular event and death within 30 days were more frequent in patients who underwent primary ERCP (p < 0.05). In multivariable analysis, adjusting for history of cardiovascular disease or events, neither risk for cardiovascular complication nor death within 30 days remained statistically significant in the ERCP group.

CONCLUSIONS

Primary ERCP as well as cholecystectomy may be performed for CBDS with acceptable safety. More studies are required to provide reliable guidelines for the management of CBDS.

Transductal versus transcystic laparoscopic common bile duct exploration: an institutional review of over four hundred cases

BACKGROUND

Many studies have failed to demonstrate significant differences between single- and two-staged approaches for the management of choledocholithiasis with concomitant gallstones in terms of post-operative morbidity. However, none of these studies paid specific attention to the differences between the methods of accessing the bile duct during laparoscopy. The aim of this study was to report outcomes of transcystic versus transductal laparoscopic common bile duct exploration (LCBDE) from our experience of over four hundred cases.

METHODS

Retrospective review of 416 consecutive patients who underwent LCBDE at a single-centre between 1998 and 2018 was performed. Data collected included pre-operative demographic information, medical co-morbidity, pre-operative investigations, intra-operative findings (including negative choledochoscopy rates, use of holmium laser lithotripsy and operative time) and post-operative outcomes.

RESULTS

Transductal LCBDE via choledochotomy was achieved in 242 patients (58.2%), whereas 174 patients (41.8%) underwent transcystic LCBDE. Stone clearance rates, conversion to open surgery and mortality were similar between the two groups. Overall morbidity as well as minor and major post-operative complications were significantly higher in the transductal group. The main surgery-related complications were bile leak (5.8% vs 1.1%, p = 0.0181) and pancreatitis (7.4% vs 0.6%, p = 0.0005). Median length of post-operative stay was also significantly greater in the transductal group.

CONCLUSION

This study represents the largest single study to date comparing outcomes from transcystic and transductal LCBDE. Where possibly, the transcystic route should be used for LCBDE and this approach can be augmented with various techniques to increase successful stone clearance and reduce the need for choledochotomy.

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.

Protocol for the CREST Choles (Chinese REgistry Study on Treatment of Cholecysto-Choledocholithiasis) study: an ambispective, multicenter, observational, open-cohort study

INTRODUCTION

The best approach for choledocholithiasis remains a matter of debate. Choledocholithiasis is usually treated with endoscopic sphincterotomy (EST), laparoscopic common bile duct exploration (LCBDE) or laparoscopic transcystic common bile duct exploration (LTCBDE). Data pertaining to the clinical outcomes of these approaches in the management of patients with cholecysto-choledocholithiasis in China are limited. An analysis of the economic burden associated with these treatments is lacking. The Chinese REgistry Study on the Treatment of Cholecysto-Choledocholithiasis (CREST Choles) was designed to address these issues in a real-world setting.

METHODS AND ANALYSIS

CREST Choles was an ambispective, multicenter, observational, open-cohort study. A total of 2700 patients undergoing one of the three treatments (EST+laparoscopic cholecystectomy (LC), LCBDE+LC and LTCBDE+LC) during the period from 1 January 2013 to 1 December 2018 at participating centres were enrolled in the study. Patients with gallstones and confirmed common bile duct stones were included. Data pertaining to demographics, disease history, procedural details, imaging features and follow-up were collected. Follow-up was conducted at least 6 months after enrolment in the study and annual follow-up will be conducted until December 2020. The primary outcome is the rate of adverse outcomes within 3 years postoperatively. Economic analysis (eg, incremental cost-effectiveness ratio) would be performed to compare expense across treatments.

ETHICS AND DISSEMINATION

Ethical approval was obtained at all participating centres. The registry presented is the first attempt to comprehensively evaluate the cost of treatment for cholecysto-choledocholithiasis in China. Findings are expected to be available in 2020 and will facilitate clinical decision making in such cases.

TRIAL REGISTRATION NUMBER

NCT02554097.

How to choose the most appropriate technique for the single-stage treatment of cholecysto-choledocolithiasis?

Background

We utilized transcystic clearance and intra-operative papillotomy through a rendezvous technique for the treatment of cholecysto-choledocolithiasis. The goal of this study was to evaluate the reliability of pre-operative parameters to address the most suitable surgical procedure.

Methods

A total of 180 patients affected by calculi of the gallbladder and bile duct underwent the single-stage treatment. According to several pre-operative parameters, 141 patients had to supposedly undergo transcystic clearance of the bile duct, while 39 patients had to be treated with the rendezvous technique. All patients were treated with the sequential procedure: first, we tried the transcystic procedure and, if there was a failure, we used a rendezvous technique. We prospectively analysed each group based on a series of variables such as sex, age, operative time, success rate of proposed treatment, conversion rate, post-operative complications and hospital stay.

Results

Transcystic clearance was successful in 134 out of 141 patients (95.0%), while 2 patients needed to undergo a laparo-endoscopy procedure (failure). Thirty-five out of 39 patients (89.7%) obtained common bile-duct (CBD) clearance through the rendezvous technique, while 1 patient obtained clean-up through the simple transcystic procedure (failure). Five out of 141 patients with transcystic clearance and 3 out of 39 patients with the rendezvous technique underwent laparotomy CBD clearance with conversion rates of 3.5% and 7.7%, respectively. Post-operative complications showed similar percentages for both procedures. However, the surgical time turned out to be longer for the rendezvous technique.

Conclusions

The one-stage procedure for the treatment of cholecysto-choledocolithiasis was possible in 94% of the cases utilizing a surgical technique selected according to the patient’s case history. The pre-operative parameters, such as jaundice, CBD diameters and stone diameters, have certified their reliability as good predictors of the most suitable procedure to follow.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Surgical (Open and laparoscopic) management of large difficult CBD stones after different sessions of endoscopic failure: A retrospective cohort study

Objectives

For complicated common bile duct stones (CBDS) that cannot be extracted by endoscopic retrograde cholangiopancreatography (ERCP), management can be safely by open or laparoscopic CBD exploration (CBDE). The study aimed to assess these surgical procedures after endoscopic failure.

Methods

We analyzed 85 patients underwent surgical management of difficult CBDS after ERCP failure, in the period from 2013 to 2018.

Results

Sixty-seven (78.8%) and 18(21.2%) of our patients underwent single and multiple ERCP sessions respectively. An impacted large stone was the most frequent cause of ERCP failure (60%). Laparoscopic CBDE(LCBDE), open CBDE(OCBDE) and the converted cases were 24.7% (n = 21), 70.6% (n = 60), and 4.7% (n = 4) respectively. Stone clearance rate post LCBDE and OCBDE reached 95.2% and 95% respectively, Eleven (12.9%) of our patients had postoperative complications without mortality. By comparing LCBDE and OCBDE; there was a significant association between the former and longer operative time. On comparing, T-tube and 1ry CBD closure in both OCBDE and LCBDE, there was significantly longer operative time, and post-operative hospital stays in the former. Furthermore, in OCBDE group, choledocoscopy had an independent direction to 1ry CBD repair and significant association with higher stone clearance rate, shorter operative time, and post-operative hospital stay.

Conclusion

Large difficult CBDS can be managed either by open surgery or laparoscopically with acceptable comparable outcomes with no need for multiple ERCP sessions due to their related morbidities; furthermore, Open choledocoscopy has a good impact on stone clearance rate with direction towards doing primary repair that is better than T-tube regarding operative time and post-operative hospital stay.

•

Large difficult CBD stones can be managed either by open surgery or laparoscopically with acceptable comparable outcomes.

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No need for multiple ERCP sessions due to their related morbidities.

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Open choledocoscopy has a good impact on stone clearance rate with direction towards doing primary repair.

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Primary repair is better than T-tube regarding operative time and post-operative hospital stay.

Surgical (Open and laparoscopic) management of large difficult CBD stones after different sessions of endoscopic failure: A retrospective cohort study

Objectives

For complicated common bile duct stones (CBDS) that cannot be extracted by endoscopic retrograde cholangiopancreatography (ERCP), management can be safely by open or laparoscopic CBD exploration (CBDE). The study aimed to assess these surgical procedures after endoscopic failure.

Methods

We analyzed 85 patients underwent surgical management of difficult CBDS after ERCP failure, in the period from 2013 to 2018.

Results

Sixty-seven (78.8%) and 18(21.2%) of our patients underwent single and multiple ERCP sessions respectively. An impacted large stone was the most frequent cause of ERCP failure (60%). Laparoscopic CBDE(LCBDE), open CBDE(OCBDE) and the converted cases were 24.7% (n = 21), 70.6% (n = 60), and 4.7% (n = 4) respectively. Stone clearance rate post LCBDE and OCBDE reached 95.2% and 95% respectively, Eleven (12.9%) of our patients had postoperative complications without mortality. By comparing LCBDE and OCBDE; there was a significant association between the former and longer operative time. On comparing, T-tube and 1ry CBD closure in both OCBDE and LCBDE, there was significantly longer operative time, and post-operative hospital stays in the former. Furthermore, in OCBDE group, choledocoscopy had an independent direction to 1ry CBD repair and significant association with higher stone clearance rate, shorter operative time, and post-operative hospital stay.

Conclusion

Large difficult CBDS can be managed either by open surgery or laparoscopically with acceptable comparable outcomes with no need for multiple ERCP sessions due to their related morbidities; furthermore, Open choledocoscopy has a good impact on stone clearance rate with direction towards doing primary repair that is better than T-tube regarding operative time and post-operative hospital stay.

Endoscopic Management of Acute Biliopancreatic Disorders

PURPOSE

Endoscopy is playing an ever-increasing role in the management of acute biliopancreatic disorders. With the management paradigm shifting away from more invasive surgical approaches, surgeons need to be aware of the treatment options available to improve patient care. Our manuscript serves to improve surgeons' knowledge and understanding of these emerging treatment modalities to expand their algorithmic approach to biliopancreatic disorders.

METHODS

Specific acute biliopancreatic disorders were identified from the literature and personal practice to create a structured review of common problems experienced by a surgeon of the gastrointestinal tract. An exhaustive literature review was performed to identify and analyze endoscopic treatment modalities for these disorders.

RESULTS

Endoscopic therapies continue to expand rapidly with a robust supportive literature. Data on endoscopic treatment strategies for acute biliopancreatic disorders demonstrate valuable improvements in outcomes in a number of these disorders.

DISCUSSION

Acute biliopancreatic disorders represent one of the most challenging pathophysiologies that a surgeon of the gastrointestinal tract may face. This manuscript represents a review of available endoscopic instrumentation as well as the author's interpretation of the current literature regarding indications and outcomes of endoscopic management for acute biliopancreatic disorders. Although this article does not supplant formal training in therapeutic endoscopy, surgeons reading this article should understand the role endoscopy plays in the management of acute biliopancreatic disorders.

Technical Aspects of Bile Duct Evaluation and Exploration: An Update

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

Laparoscopic transcystic common bile duct exploration: surgical indications and procedure strategies

BACKGROUND

LTCBDE combined with or without modified techniques is safe and efficacious for the management of gallstones and concomitant, even large, common bile duct (CBD) stones.

METHODS

To describe the surgical indications and procedure strategies of laparoscopic transcystic common bile duct exploration (LTCBDE), a retrospective analysis of 205 patients with concomitant gallstones and CBD stones treated using LTCBDE between June 2008 and June 2015 was performed. Clinical data on disease characteristics, methods for cystic duct incision and CBD stone extraction (with or without laser lithotripsy), and surgical outcomes were collected and reviewed.

RESULTS

CBD stones were successfully cleared in all patients. No patient was converted to choledochotomy or laparotomy. The cystic duct diameter ranged 3-8 mm, and 85 patients with cystic duct diameter ≥ 5 mm. The mean time for CBD stone extraction was 25.3 min, with the operative time ranged from 63 to 170 min. Lithotripsy was used in 74 (36.1%) patients among which 26 patients with cystic duct diameter ≥ 5 mm. Estimated blood loss during surgery was 10-120 ml per patient, and no intra-operative blood transfusions were needed. The mean postoperative hospital stay was 5.1 (range 3-7) days, and postoperative complications developed in seven patients. No bile duct injury, stricture, remnant, recurrent stones, or other adverse events were observed during the mean follow-up of 8 months.

CONCLUSIONS

Based on preoperative MRCP and intra-operative IOC findings about cystic duct diameter, the diameter of CBD, CBD stone size, we summarized and proposed the surgical indications and suitable techniques and strategies during LTCBDE.

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.

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

BACKGROUND

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

DATA SOURCES

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

RESULTS

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

CONCLUSION

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

Single-stage procedure for the treatment of cholecysto-choledocolithiasis: a surgical procedures review

While laparoscopic cholecystectomy is generally accepted as the treatment of choice for simple gallbladder stones, in cases in which common bile duct stones are also present, clinical and diagnostic elements, along with intraoperative findings, define the optimal means of treatment. All available options must be accessible to the surgical team which must necessarily be multidisciplinary and include a surgeon, an endoscopist, and a radiologist in order to identify the best option for a truly personalized surgery. This review describes the different techniques and approaches used based on distinctive recommendations and factors, according to the specific cases treated and the results achieved.

Efficacy of the Laparoendoscopic "Rendezvous" to Treat Cholecystocholedocholithiasis in 210 Consecutive Patients: A Single Center Experience

OBJECTIVE

The simultaneous laparoendoscopic "rendezvous" (LERV) represents an alternative to sequential or totally laparoscopic approaches for patients affected by cholecystocholedocholithiasis. The aim of this study was to analyze the results in a large series of 210 consecutive patients.

MATERIALS AND METHODS

From 2002 to 2016 all patients affected by cholecystocholedocholithiasis were treated with a standardized "tailored" LERV. The relevant technical features of the procedure were recorded. An analysis of feasibility, effectiveness in stone clearance, and safety was performed.

RESULTS

Among 214 patients with common bile duct stones, 210 were treated with LERV and 4 with open rendezvous approach. Intraoperative cholangiography confirmed common bile duct stones in 179 patients (85.2%) or sludge in 18 (8.5%) and in 98.9% stone clearance was obtained endoscopically. Endoscopic papilla cannulation was feasible in 161 patients (76.7%), whereas in 49 (23.3%) a transcystic guidewire was needed. The overall LERV feasibility was 96.6%. The conversion rate to open surgery was 3.3%. Minor morbidity was observed in 1.9% of cases, mortality in 0.47%, and the mean hospital stay was 4.3 days.

CONCLUSIONS

These results confirm the high effectiveness of LERV. This approach to treat cholecystocholedocholithiasis should be preferred and therefore implemented where a strong collaboration between surgeons and endoscopists is possible.

Three modalities on management of choledocholithiasis: A prospective cohort study

BACKGROUND

Choledocholithiasis can be managed by endoscopic retrograde cholangiopancreaticography/endoscopic sphincterotomy (ERCP/EST) or laparoscopic common bile duct (CBD) exploration by transcystic (TC) or transductal (TD) stone extraction.

OBJECTIVE

The aim of this study was to evaluate the safety and effectiveness of common bile duct stones extraction by ERCP/EST, TC approach and TD approach for choledocholithiasis, with specific emphasis on ERCP/EST, TC approach versus TD approach.

METHODS

Between January 2011 and June 2014, a total of 161 patients were scheduled for two-stage (preoperative ERCP/EST followed by cholecystectomy, ERCP group, n = 52)or single-stage (laparoscopic exploration of the CBD combined with cholecystectomy, n = 109) treatment for choledocholithiasis with concomitant cholecystitis. Laparoscopic common bile duct exploration was performed by TC approach (TC group, n = 63)or TD approach (TD group, n = 46). T-tube insertion was performed in selected patients. Patients were regularly followed up at bimonthly intervals or more frequently in presence of any symptom. Primary outcomes measures included length of hospital stay, successful bile duct clearance, postoperative/procedural morbidity and mortality.

RESULTS

Successful bile duct clearance was 100.0% in TD group, 93.7% in TC group and 92.3% in ERCP group. 4 cases in the TC group and 4 cases in the ERCP group required an extra choledocholithotomy due to impacted stones. 9 patients underwent T-tube drainage in TD group comparing to 1 case in ERCP group and no cases in TC group. Comparing to TC group, there was more postoperative morbidity in TD and ERCP group. Bile leaks were more frequent in TD group (8.7%) than TC (3.2%) and ERCP group (3.8%), which prolonged hospitalization in TD group than TC and ERCP group. 2 patients in ERCP group suffered duodenal perforation and one of them died because of the complication. However, total procedural morbidity was 0% in TC and TD group.

CONCLUSION

TD stone extraction has a higher stone clearance but with a higher risk of bile leaks. Procedural morbidity is more often happened in ERCP/EST, which may result in serious consequences. TC stone extraction, which seems an effective approach with lower complication rates, is accessible techniques simplifying the operation procedure by avoiding choledocholithotomy and subsequent T-tube insertion.

Laparoscopic Transcystic Treatment Biliary Calculi by Laser Lithotripsy

BACKGROUND AND OBJECTIVES

Laparoscopic transcystic common bile duct exploration (LTCBDE) is a complex procedure requiring expertise in laparoscopic and choledochoscopic skills. The purpose of this study was to investigate the safety and feasibility of treating biliary calculi through laparoscopic transcystic exploration of the CBD via an ultrathin choledochoscope combined with dual-frequency laser lithotripsy.

METHODS

From August 2011 through September 2014, 89 patients at our hospital were treated for cholecystolithiasis with biliary calculi. Patients underwent laparoscopic cholecystectomy and exploration of the CBD via the cystic duct and the choledochoscope instrument channel. A dual-band, dual-pulse laser lithotripsy system was used to destroy the calculi. Two intermittent laser emissions (intensity, 0.12 J; pulse width 1.2 μs; and pulse frequency, 10 Hz) were applied during each contact with the calculi. The stones were washed out by water injection or removed by a stone-retrieval basket.

RESULTS

Biliary calculi were removed in 1 treatment in all 89 patients. No biliary tract injury or bile leakage was observed. Follow-up examination with type-B ultrasonography or magnetic resonance cholangiopancreatography 3 months after surgery revealed no instances of retained-calculi-related biliary tract stenosis.

CONCLUSION

The combined use of laparoscopic transcystic CBD exploration by ultrathin choledochoscopy and dual-frequency laser lithotripsy offers an accurate, convenient, safe, effective method of treating biliary calculi.

Laparoscopic Transcystic Common Bile Duct Exploration: Advantages over Laparoscopic Choledochotomy

Purpose

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

Methods

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

Results

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

Conclusions

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

Impact of intraoperative cholangiography on postoperative morbidity and readmission: analysis of the NSQIP database

BACKGROUND

The debate regarding the merits of routine use of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) continues to rage. We aim to analyze the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to identify patterns of utilization of cholangiography during LC as well as its impact on patient outcomes.

STUDY DESIGN

This is a retrospective cohort study of patients undergoing LC with or without IOC in the 2012 and 2013 ACS NSQIP database. Only patients without any preoperative biochemical evidence of the CBD stone were included in the analysis. Comparison between two groups and data analysis focused on the following primary outcomes: 30-day mortality, readmission, return to operating room and NSQIP collected morbidity.

RESULTS

Twenty-one percentage of patients undergoing LC without any biochemical abnormality are undergoing IOC. There were no statistically significant differences in thirty-day outcomes between two patient populations with regard to mortality, morbidity, cardiac, central nervous system, wound, deep vein thrombosis, sepsis, respiratory and urinary tract complications. Patients undergoing LC plus IOC were found to have statistically significant reduction in the rate of readmission related to the first operation (adjusted odds ratio 0.80, 95 % CI 0.70-0.92; P value = 0.002). Readmissions related to biliary complications including retained CBD following cholecystectomy were 1.61 times more likely in patients who underwent LC without cholangiography.

CONCLUSION

The use of IOC at the time of LC appears to be associated with a statistically significant decrease in re-admission rates, especially readmissions related to biliary complications.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Learning curve and outcome of laparoscopic transcystic common bile duct exploration for choledocholithiasis

BACKGROUND

The best approach for cholecystocholedocholithiasis remains a matter of debate. The aim of this study was to evaluate the technical aspects, learning curve and outcome of laparoscopic transcystic common bile duct exploration (LTCBDE).

METHODS

Patients who underwent laparoscopic cholecystectomy with LTCBDE between January 2007 and December 2012 were identified from an institutional database. Data on preoperative investigations, intraoperative and postoperative findings were retrieved retrospectively from the patients' hospital notes.

RESULTS

There were 399 women (56·4 per cent) and 309 men (43·6 per cent), with a median age of 58 (range 18-87) years. Microincision (incision of the cystic duct at the confluence with the common bile duct (CBD) with extension of only 3-5 mm at the lateral margin of the CBD) and lithotripsy were used in the transcystic exploration in 119 patients, and increased the success rate of LTCBDE from 74·2 to 91·0 per cent. The median duration of operation was 85 (i.q.r. 65-120) min and the median postoperative hospital stay was 2 (1-3) days. Retained common bile duct stones were observed in 13 patients, and postoperative complications developed in 27 patients. The cumulative sum duration of operation learning curve comprised two phases; phase 1 included the first 250 patients and phase 2 the remaining 458 patients. Duration of operation and postoperative hospital stay decreased with increasing volume per surgeon. Recurrence of common bile duct stones was diagnosed in 26 patients during a median follow-up of 4 years.

CONCLUSION

LTCBDE with or without microincision and/or lithotripsy is a safe and effective approach.

Eleven years of primary closure of common bile duct after choledochotomy for choledocholithiasis

BACKGROUND

The choice of surgical technique to extract stones from the common bile duct (CBD) depends on local experience, anatomical characteristics and also on the size, location and number of stones. Most authors consider choledochotomy an alternative to failed transcystic exploration, although some use it exclusively. Although the CBD is traditionally closed with T-tube drainage after choledochotomy, its use is associated with 11.3-27.5 % morbidity. This study examined the efficacy of laparoscopic CBD exploration (LCBDE) with primary closure for the treatment of CBD stones using intraoperative cholangiography (IOC).

METHODS

Retrospective study of 160 patients who underwent LCBDE with primary closure after choledochotomy between January 2001 and December 2012.

RESULTS

The diagnosis of choledocholithiasis was definitively made in all cases by IOC. The overall complication rate was 15 % and the biliary complication rate was 7.5 %. Bile leakage was reported in 11 patients (6.8 %). In over half the cases (63.6 %), no further action was required and the leak closed spontaneously. Six patients were reoperated (3.75 %), two for bile peritonitis and four for haemoperitoneum. The success rate for stone clearance was 96.2 %. The mortality rate and CBD stricture rate were 0 %.

CONCLUSION

Primary closure after choledochotomy to clear stones from the CBD is a safe technique that confers excellent results and allows one-stage treatment.

Surgeons, ERCP, and laparoscopic common bile duct exploration: do we need a standard approach for common bile duct stones?

BACKGROUND

Variation exists in the management of choledocholithiasis (CDL). This study evaluated associations between demographic and practice-related characteristics and CDL management.

METHODS

A 22-item, web-based survey was administered to US general surgeons. Respondents were classified into metropolitan or nonmetropolitan groups by zip code. Univariate tests and multivariable logistic regression were used to determine factors associated with CDL management preferences.

RESULTS

The survey was sent to 32,932 surgeons; 9902 performed laparoscopic cholecystectomy within the last year; 750 of 771 respondents had a valid US zip code and were included in the analysis. Mean practice time was 18 ± 10 years, 87% were male, and 83% practiced in a metropolitan area. For preoperatively known CDL, 86% chose preoperative endoscopic retrograde cholangiopancreatography (ERCP). Those in metropolitan areas were more likely to select preoperative ERCP than those in nonmetropolitan areas (88 vs. 79%, p < 0.001). For CDL discovered intraoperatively, 30% selected laparoscopic common bile duct exploration (LCBDE) as their preferred method of management with no difference between metropolitan and nonmetropolitan areas (30 vs. 26%, p = 0.335). The top reasons for not performing LCBDE were: having a reliable ERCP proceduralist available, lack of equipment, and lack of comfort performing LCBDE. Factors associated with preoperative ERCP were: metropolitan status, selective intraoperative cholangiography (IOC), and availability of a reliable ERCP proceduralist. Those who perform selective IOC were 70% less likely to prefer LCBDE (OR 0.32, 95% CI 0.18-0.57, p < 0.001). Those with a reliable ERCP proceduralist available were 90% less likely to prefer LCBDE (OR 0.10, 95% CI 0.04-0.26, p < 0.001).

CONCLUSIONS

The majority of respondents preferred ERCP for the management of CDL. Having a reliable ERCP proceduralist available, use of selective IOC, and metropolitan status were independently associated with preoperative ERCP. Postoperative ERCP was preferred for managing intraoperatively discovered CDL. Many surgeons are uncomfortable performing LCBDE, and increased training may be needed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Which differences do elderly patients present in single-stage treatment for cholecysto-choledocholithiasis?

Patients with symptomatic gallstones present common bile duct stones in approximately 10% of cases. It is possible to resolve both gallbladder and bile duct stones with a single procedure. The aim of this study is to determine the effectiveness of a single stage procedure for gallbladder and bile duct stones in the elderly patients and to expose the differences between the various techniques. From January 2008 to December 2013, we treated 1540 patients with gallbladder stones. In 152 cases, we also found bile duct stones. 150 of these were treated in a single stage procedure. We divided our patients into 2 groups: Group A was younger than 65 (104 patients); Group B was 65 or older (46 patients). We retrospectively compared sex, ASA score, conversion rate, success rate, post-operative complications, hospital stay, and treatment method. We had no intra-operative mortality. 1 patient in Group B, heart condition (ASA 4), died with multiple organ failure (MOF) 10 days after his operation. ASA score: 3.5 ± 0.5 in A vs 2 ± 0.9 in B (P 0.001), post-operative complications 6% in A vs 18.1% in B (P 0.0325) and hospital stay 4.1 ± 2.3 in A vs 9.5 ± 5.5 in B (P 0.0001) were significantly higher in Group B. No differences were found in term of success rate: 94% in A vs 90% in B (P 0.4944). The procedure used to obtain the clearance of the bile duct showed a different success rate across the two groups: for the patients under 65 years old, trans-cystic clearance (TC-CBDE) was successful in 90% of cases, and only 51% for those older than 65, where we had to recall 49% for laparo-endoscopic rendez-vous (RV-IOERC) (P 0.0014). In conclusion, single stage treatment is safe and effective also to elderly patients. The methods used in patients being younger than 65 years old is what appeared to be significantly different.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Short-term outcomes of laparoscopic transcystic common bile duct exploration with discharge less than 24 hours

BACKGROUND

Reducing the length of stay and discharge time for patients could benefit multiple hospital units by saving money, reducing waiting time, and providing the opportunity for more patients to be treated. However, no experience of laparoscopic transcystic common bile duct exploration (LTCBDE) with discharge less than 24 hours has been reported until now. The objective of this study was to assess the feasibility and safety of LTCBDE with discharge less than 24 hours.

PATIENTS AND METHODS

A retrospective review showed that 34 of 111 patients scheduled in our institution were discharged less than 24 hours after LTCBDE between June 1 and December 31, 2011. A multimodal approach including appropriate preoperative assessment, education and counseling, early postoperative oral intake, and early mobilization was carried out. Outcomes were analyzed for patient demographics, postoperative stay, operation time, intraoperative bleeding, and reasons for failed LTCBDE.

RESULTS

Of 111 patients admitted for LTCBDE, 34 patients were discharged within 24 hours postoperatively. This study population comprised 11 males and 23 females with a mean age of 54.6±14.7 years (range, 28-79 years). The mean postoperative stay was 20.21±0.39 hours. There were no postoperative complications or deaths during the hospital stay or at the follow-up 12 months postoperatively in these 34 patients.

CONCLUSIONS

LTCBDE with discharge less than 24 hours is feasible and safe in selected patients with common bile duct stones of no more than three in number and no more than 6 mm in size. The benefit of the multimodal approach and LTCBDE may be synergistic, allowing a quick recovery of gastrointestinal function.

Laparoscopic common bile duct exploration. Lessons learned after 200 cases

INTRODUCTION

Laparoscopic common bile duct exploration (LCBDE) is a reliable, reproducible and cost-effective treatment for common bile duct stones. Several techniques have been described for choledochotomy closure.

AIMS

To present our experience and the lessons learned in more than 200 cases of LCBDE.

PATIENTS AND METHODS

Between January 1999 and July 2012, 206 patients with common bile duct stones underwent LCBDE. At the beginning of the series, we performed the closure of the CBD over a T-tube (36 patients), subsequently we favoured closure over an antegrade stent (133 patients) but due to a high incidence of acute pancreatitis in the last 16 patients we have performed primary closure.

RESULTS

The 3 closure groups were matched for age and sex. Jaundice was the most frequent presentation. A total of 185 (88,5%) patients underwent choledochotomy whereas in 17 (8,7%) patients the transcystic route was used. The group that underwent choledochotomy had a larger size of stones compared to the transcystic group (9,7 vs 7,6mm). In the stented group we found an 11,6% incidence of pancreatitis and 26,1% of hyperamylasemia. In the primary closure group we found a clear improvement of complications and hospital stay. The increased experience of the surgeon and age (younger than 75) had a positive impact on mortality and morbidity.

CONCLUSIONS

Primary closure of the common bile duct after LCBDE seems to be superior to closure over a T tube and stents. The learning curve seems to have a positive impact on the outcomes making it a safe and reproducible technique especially for patients aged under 75.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Application of electrohydraulic lithotripsy combined with choledochoscopy in laparoscopic transcystic common bile duct exploration

AIM: To evaluate the application value of electrohydraulic lithotripsy combined with choledochoscope in laparoscopic transcystic common bile duct exploration (LTCBDE).

METHODS: Twenty-four patients who were diagnosed with gallbladder stones with common bile duct stones by magnetic resonance cholangiopancreatography underwent LTCBDE. The minimal diameter of stones was 1.6 cm. The hospital stay, operative time and postoperative complications were recorded.

RESULTS: LTCBDE was successful in all the cases. The operative time and hospital stay were 75-210 min and 3-7 d, respectively. One of the patients had residual stones (4.2%) and recovered without treatment.

CONCLUSION: Electrohydraulic lithotripsy combined with choledochoscopy in LTCBDE is an effective and safe way to treat greater stones.

Comparison of long-term outcomes after endoscopic sphincterotomy versus endoscopic papillary balloon dilation: a propensity score-based cohort analysis

BACKGROUND

Endoscopic sphincterotomy (ES) is widely performed in patients with common bile duct stones (CBDS). However, the long-term outcomes of patients following ES have not been sufficiently elucidated. Impaired papillary function following ES may result in additional late complications. In contrast, endoscopic papillary balloon dilation (EPBD)-another option for treating CBDS-is expected to preserve papillary function. This study aimed to compare the long-term outcomes of patients with CBDS treated with ES to those treated with EPBD in a large cohort. In addition, a subgroup analysis was performed, according to gallbladder (GB) status.

METHODS

A cohort study was performed using propensity score matching to reduce treatment selection bias. This involved the analysis of follow-up data for 1086 patients who underwent EPBD or ES for CBDS.

RESULTS

Propensity score matching extracted 246 pairs of patients. The median (interquartile range) follow-up period after EPBD or ES was 93.5 (46.8-129.2) months and 90 (42-139.3) months, respectively. The incidence of CBDS recurrence after EPBD and ES were 8.5 and 15.0 %, respectively. The hazard ratio (95 % CI) was 0.577 (0.338-0.986) (P = 0.044). Based on the status of the GB, the incidence of CBDS recurrence was significantly different between post-EPBD and post-ES in the group with cholecystectomy after EPBD/ES (P = 0.013).

CONCLUSIONS

The incidence of biliary complications was significantly lower in patients after EPBD than in those after ES, and this outcome appeared most markedly in patients who also underwent cholecystectomy.

Minimally invasive treatment of cholecysto-choledocal lithiasis: The point of view of the surgical endoscopist

The rate of choledocholithiasis in patients with symptomatic cholelithiasis is estimated to be approximately 10%-33%, depending on the patient’s age. Development of Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Surgery and improvement of diagnostic procedures have influenced new approaches to the management of common bile duct stones in association with gallstones. At present available minimally-invasive treatments of cholecysto-choledocal lithiasis include: single-stage laparoscopic treatment, perioperative endoscopic treatment and endoscopic treatment alone. Published data evidence that, associated endoscopic-laparoscopic approach necessitates increased number of procedures per patient while single-stage laparoscopic treatment is associated with a shorter hospital stay. However, current data does not suggest clear superiority of any one approach with regard to success, mortality, morbidity and cost-effectiveness. Considering the variety of therapeutic options available for management, a critical appraisal and decision-making is required. Endoscopic retrograde cholangiopancreatography/EST should be adopted on a selective basis, i.e., in patients with acute obstructive suppurative cholangitis, severe biliary pancreatitis, ampullary stone impaction or severe comorbidity. In a setting where all facilities are available, decision in the selection of the therapeutic option depends on the patients, the number and size of choledocholithiasis stones, the anatomy of the cystic duct and common bile duct, the surgical history of patients and local expertise.