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

Comparative Efficacy and Complications Between One-stage Transcystic Common Bile Duct Exploration and Two-stage ERCP Plus Laparoscopic Cholecystectomy for Treatment of Choledocholithiasis: A Systematic Review and Meta-analysis

BACKGROUND

Early and effective management of choledocholithiasis is imperative to decrease patient morbidity. Despite the widespread use of ERCP, advancements in laparoscopy and choledochoscopy have renewed interest in laparoscopic CBD exploration (LCBDE). This meta-analysis compares outcomes of 2-stage ERCP followed by laparoscopic cholecystectomy (LC) versus one-stage transcystic LCBDE plus LC.

METHODS

A comprehensive literature search was performed in PubMed, CENTRAL, and Embase databases according to PRISMA guidelines. Studies were selected based on specific criteria. Data on stone clearance, postoperative pancreatitis, bleeding, mortality, and length of stay were extracted.

RESULTS

Seven comparative non-randomized studies enrolling 669 "one-stage LCBDE patients" and 724 "two-stage ERCP patients" were included. Overall, there were no statistically significant differences regarding the rates of stone clearance, pancreatitis, bleeding, and mortality between the 2 groups.

CONCLUSION

One-stage transcystic LCBDE is noninferior to the 2-stage ERCP + LC approach, supporting its use as a first-line treatment for choledocholithiasis.

Comparison of the efficacy of LTCBDE and LCBDE for common bile duct stones: a systematic review and meta-analysis

Background

The choice of surgical methods for common bile duct stones (CBDS) is controversial. The aim of this study was to compare the safety and efficacy of laparoscopic transcystic common bile duct exploration (LTCBDE) and laparoscopic common bile duct exploration (LCBDE).

Methods

Relevant literature published before March 30, 2023 in PubMed, Web of Science, Embase, and Cochrane was searched to screen studies comparing LTCBDE and LCBDE. RevMan 5.4 was used for meta-analysis of fixed-effects and random-effects models.

Results

A total of 21 studies met the inclusion criteria, including 3065 patients in the LTCBDE group and 2,453 patients in the LCBDE group. CBDS clearance was 95.4% (2,682/2,812) in LTCBDE group and 94.7% (1,810/1,911) in LCBDE group (OR: 1.84, 95% CI: 1.36, 2.48, P < 0.0001; I 2 = 0%, P = 0.56). In LTCBDE group, operative time(MD = -34.60, 95% CI: -46.05, -23, 15, P < 0.00001 I 2 = 96%, P < 0.00001), postoperative hospital stay (MD = -2.92, 95% CI: -3.62, -2.21, P < 0.00001; I 2 = 92%, P < 0.00001), postoperative complications (OR: 0.47, 95% CI: 0.38, 0.58, P < 0.0001; I 2 = 26%, P = 0.15), residual stone(OR: 0.48, 95% CI: 0.34, 0.66, P < 0.0001; I 2 = 0%, P = 0.56), bile leak (OR: 0.37, 95% CI: 0.25, 0.55, P < 0.00001; I 2 = 0%,P = 0.52), mortality (OR: 0.10, 95% CI: 0.01, 0.88, P = 0.04; I 2 = 0%, P = 0.71) and recurrent stones(OR: 0.34, 95% CI: 0.15, 0.74, P = 0.007; I 2 = 5%, P = 0.38) were better than LCBDE group. There was no difference in pancreatitis (OR: 1.06, 95% CI: 0.52, 2.16. P = 0.86; I 2 = 0%, P = 0.98) and biliary stricture(OR: 0.30, 95% CI: 0.08, 1.09, P = 0.07; I 2 = 0%, P = 0.57).

Conclusions

LTCBDE is safe, efficient, and of great clinical significance, and is worth promoting to some patients.

Laparoscopic Ultrasound-Guided Transcystic Approach for the Treatment of Common Bile Duct Stones

Background: The treatment of choledocholithiasis with nondilated common bile duct (CBD) is a challenge for surgeons who often choose endoscopic retrograde cholangiopancreatography with laparoscopic cholecystectomy (LC) staging surgery instead of simultaneous laparoscopic CBD exploration with LC because of the small CBD diameter. This study aims to introduce and assess the clinical applicability of a technique we developed to identify and extract CBD stones using laparoscopic ultrasound (LUS). Methods: We retrospectively reviewed surgical procedures and clinical data of 13 patients who underwent LC and CBD exploration using LUS between May 2022 and August 2023. The cystic duct was used for CBD stone removal. Results: Ten patients were successfully treated; 2 patients with residual stones were treated with ursodeoxycholic acid, whereas 1 patient required a microincision near the CBD and choledochoscopy because of stone incarceration in the duodenal papilla. The CBD diameter was 6 mm (5-9 mm). There were less than three CBD stones, with diameters of 2-6 mm; the median operative time was 105 minutes (range, 52-155 minutes). One patient developed postoperative cholangitis. The median postoperative hospital stay was 6 days (3-8 days). The stone clearance rate was 76.9%, and the CBD stone detection rate was 100%. No intraoperative complications, postoperative bile leakage, and mortality occurred. Conclusions: CBD exploration and transcystic stone extraction under LUS guidance are safe and effective approaches for patients with choledocholithiasis; strict control over surgical indications is necessary. This study could provide new strategies for effectively treating choledocholithiasis.

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

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

TAVAC: choledochoscopy disposable scopes, and the single-stage vs. two-stage approach to choledocholithiasis

BACKGROUND

Previous studies have been published evaluating the benefits and drawbacks of clearing the common bile duct of stones using a single-stage approach (LCBDE + LC) versus a two-stage approach (ERCP followed by LC). These studies have demonstrated that a single-stage approach offers similar outcomes and morbidities as a two-stage approach, with the added benefit of a lower cost and shorter length of stays. However, it is significant we understand why LCBDE is not commonly performed currently and also the lapse in surgical trainee exposure and competence in LCBDE. This paper aims to address the lapse in surgical trainee exposure to LCBDE, evaluate the scopes currently available to perform LCBDE, and review current data evaluating the risks and benefits of single-stage versus two-stage approaches to.

METHODS

We utilized PubMed to analyze all publications related to the various disposable scopes utilized to perform choledochoscopy. We also discuss the need for disposable scopes and how this new market niche is transforming the choledochoscopy space.

RESULTS

We analyzed the data related to single-stage and two-stage approach to choledocholithiasis. We noted an overall shorter length of stay and also decreased costs in favor of a single-stage approach.

CONCLUSION

A single-stage LCBDE is the most cost-effective treatment option for choledocholithiasis in patients with choledocholithiasis undergoing a cholecystectomy. In addition, single-stage approach is associated with shorter length of stay. Knowledge of the available choledochoscopes and tools available to surgeons to perform choledochoscopy is significant. The evidence does support the use of disposable choledochoscope from a cost and cross-contamination perspective. Additionally, efforts should be made to incorporate LCBDE into the teaching paradigm of surgical training programs.

Five-Year Experience with Transcystic Laparoscopic Common Bile Duct Exploration

Background: Common bile duct (CBD) stones associated with cholecystitis can be treated by single-stage CBD exploration at the time of cholecystectomy or a two-stage approach with endoscopic stone extraction before or after cholecystectomy. The ideal management remains a matter of debate. The aim of this study is to analyze our outcomes with transcystic laparoscopic common bile duct exploration (LCBDE). Material and Methods: A retrospective review of patients who underwent transcystic LCBDE between 2015 and 2019 was performed. Results: A total of 106 patients underwent transcystic LCBDE over 5 years. We performed 1192 laparoscopic cholecystectomies with cholangiograms from March 2015 to December 2019. Fifteen patients had a preoperative endoscopic retrograde cholangiopancreatography (ERCP) for CBD stones seen on magnetic resonance cholangiopancreatography that during laparoscopic cholecystectomy with intraoperative cholangiogram (IOC), there were stones and/or sludge found in the CBD, which required clearance through a transcystic approach. Of the 91 patients who did not have a preoperative ERCP, clearance of the CBD was successful through a transcystic approach in 78 patients (86%). In the 13 patients that intraoperative clearance was not achieved (n = 13, 14%), a postoperative ERCP was performed. A total of 28 patients underwent either pre- or postoperative ERCP (n = 28, 26%). Choledochotomy was not performed in any of the patients. The mean operative time was 127 minutes (127 ± 48). The mean hospital length of stay (LOS) was 4 days (3.9 ± 2.8) with a median LOS of 3 days. Complications observed include wound infection (n = 2, 2%), pancreatitis after ERCP (n = 1, 1%), pneumonia (n = 1, 1%), and right hepatic duct injury (n = 1, 1%). Conclusion: Transcystic LCBDE is an effective and safe option for treatment of CBD stones. While a transcystic approach does not guarantee clearance of the CBD, it avoids the morbidity associated with a choledochotomy and can often prevent patients from having to undergo an additional procedure.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Analysis of Laparoscopic Ultrathin Choledochoscope Curative Effect on Common Bile Duct Exploration and Choledocholithotomy in 47 Cases

Objective

The aim of the present study is to summarize the experience of using a 2. 7 mm choledochoscope for laparoscopic cholecystectomy combined with an ultrathin choledochoscope for common bile duct exploration and choledocholithotomy in the treatment of cholecystolithiasis associated with choledocholithiasis after the implementation of strict inclusion and exclusion criteria.

Methods

A retrospective analysis of 47 patients with cholecystolithiasis complicated with choledocholithiasis who were treated in the hepatopancreatobiliary surgery department of the Chinese People's Liberated Army General Hospital between January 2015 and December 2019 was performed in the present study. Clinical data of laparoscopic cholecystectomy combined with ultrathin choledochoscope transcystic duct exploration for common bile duct and choledocholithotomy.

Results

All 47 patients completed the operation successfully. The gallbladder duct was closed using a surgical clamp. Only 2 patients were administered with an abdominal drainage tube. The operation time was 50-160 min, the intraoperative blood loss was 5-50 ml, and the postoperative hospital stay was 2-8 days. No patients had serious complications, such as bile leakage, postoperative bleeding, cholangitis, biliary pancreatitis, and wound infection. Minor complications, such as abdominal pain (Abdominal pain was defined as a patient felt tolerable or unbearable abdominal pain but improved or disappeared with medication) and diarrhea, were present in a few patients; these improved after conservative treatment. There was no recurrence of calculi during the 1-5 years of follow-up, and the patient quality of life was good.

Conclusion

Laparoscopic cholecystectomy combined with ultrathin choledochoscope common bile duct exploration and choledocholithotomy is a safe and effective method after adopting strict inclusion and exclusion criteria. This technology was started in the First Medical Center, Chinese People's Liberation Army General Hospital in September 2009, and it has become extremely mature in the past 5 years.

Is the use of fully covered metal stents effective in the treatment of difficult lithiasis of the common bile duct?

BACKGROUND

The management of difficult lithiasis of common bile duct (CBD) often requires a multimodal approach. Fully Covered Metal Stents (FCSEMS) could fragment the stones, dilate strictures of the CBD and progressively enlarge the papillary orifice. The aim of the study was to evaluate the efficacy of FCSEMS in the treatment of difficult lithiasis of CBD.

METHODS

All consecutive cases of difficult lithiasis of CBD after an attempt of clearance with complete sphincterotomy were retrospectively considered from 2009 to 2019. Intrahepatic lithiasis cases were excluded. Multivariable analysis (stepwise logistic regression if p value < 0.1 at univariable analysis) was made to understand factors associated with efficacy of FCSEMS in difficult lithiasis of CBD.

RESULTS

163 cases of difficult lithiasis over 1516 cases of lithiasis of CBD (incidence of 11%) were considered. Among eligible patients, 96 (mean age 78 ± 11.9 years, 43% males) placed a FCSEMS during the first ERCP. Mean diameter of stone was 17.5 ± 5.5 mm. An attempt of dilation during the same procedure was made in 18% cases. After removal of the stent, 52 (54%) patients had complete clearance of CBD at cholangiography. The rest of patients (44), subsequently underwent multimodal treatment (final success of 95%). After logistic regression, variables positively associated with clearance of CBD were sex male (OR 3.5) and stent permanence ≥ 30 days (OR 3.2). Diameter of the stone ≥ 2 cm was associated with failure (OR 0.2). 7 post-ERCP pancreatitis, 6 post-sphincterotomy bleeding and 3 cholangitis occurred.

CONCLUSIONS

FCSEMS are useful in the approach of difficult lithiasis of CBD with no significant adverse events associated.

Optimal treatment for concomitant gallbladder stones with common bile duct stones and predictors for recurrence of common bile duct stones

BACKGROUND

The optimal treatment for concomitant gallbladder (GB) stones with common bile duct (CBD) stones and predictors for recurrence of CBD stones are not established.

METHODS

This single-center, retrospective study reviewed 466 patients diagnosed with a first event of concomitant GB stones with CBD stones from January 2010 to December 2018.

RESULTS

92 patients underwent single-stage laparoscopic CBD exploration (LCBDE) and laparoscopic cholecystectomy (LC) (group1), 108 underwent LCBDE + LC after endoscopic stone extraction (ESE) failure (group2), and 266 underwent ESE + LC (group3). Clearance (95.7 vs. 99.1 vs. 97.0%, p = 0.324) and recurrence rates (5.4 vs. 13.0 vs. 7.9%, p = 0.138) did not differ between groups. Group1 had fewer procedures (p < 0.001), lower post-treatment complication rates (7.6 vs. 18.5 vs. 13.9%, p = 0.082), and shorter hospital stay after the first procedure (5.7 vs 13.0 vs 9.8 days, p < 0.001). 40 patients (8.6%) had recurrence of CBD stones at mean follow-up of 17.1 months, of which 29 (72.5%) occurred within 24 months. In multivariate analysis, a CBD diameter > 8 mm, combined type-1 periampullary diverticulum, and age > 70 years were significant predictors of recurrence.

CONCLUSION

Single-stage LCBDE + LC is a safe and effective treatment for concomitant GB stones with CBD stones compared to ESE + LC. LCBDE should be considered in patients with a high risk of ESE failure. Careful follow-up is recommended for patients at high risk of recurrence of CBD stones, especially within 24 months after surgical or endoscopic treatment.

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.

Laparoscopic Management of Common Bile Duct Stones: Stratifying Risks, a District Hospital Experience

Background: Management of bile duct stones is variable. Selection of the appropriate treatment modality based on identifiable risk factors can increase the chances of a successful outcome. The aim of this study is to identify factors affecting outcomes of a laparoscopic bile duct exploration. Methods: Retrospective data analysis of consecutive laparoscopic bile duct explorations over a period of 13 years at a district general hospital. Results: The total number of patients in the study was 85. Elective explorations were 56 while 29 were emergency procedures. The mean operative time was 154 minutes. The conversion rate was 14% with failure to extract stones being the most common reason. Forty-two percent of conversions were in nonelective procedures and 17% in previous endoscopic retrograde cholangiopancreatography (ERCP) failures. Eleven percent patients had a transcystic clearance of bile duct and the largest stone removed transcystic was 5 mm. The largest stone removed by a laparoscopic choledochotomy was 15 mm and stones >20 mm were removed on conversion. Seven patients (8%) had a postoperative bile leak, 4 of these required a postoperative ERCP stent and radiological drainage while 3 required a reoperation. Three patients had retained stones treated by postoperative ERCP. Conclusion: Emergency procedures, increasing number and size of stones, previous failed ERCP are factors that contribute to the outcomes of a laparoscopic bile duct exploration. The chances of a successful exploration can be improved by appropriate patient and procedure selection and preparation based on identification of these factors.

Porcine Aorto-Renal Artery (PARA) model for laparoscopic transcystic common bile duct exploration: the evolution of a training model to meet new clinical needs

BACKGROUND

The transcystic approach to laparoscopic common bile duct exploration has gained popularity for the single-stage management of choledocholithiasis with concomitant gallstones. Our team previously described the use of a porcine aorta segment to simulate the common bile duct during laparoscopic skill training.

METHODS

With the advent of the transcystic approach as a contender for the first-line technique of accessing the common bile duct, we present an evolution of the laparoscopic training model using a Porcine Aorta-Renal Artery (PARA) specimen to simulate the structural integrity, dimensions and spatial distribution of both the human cystic and common bile ducts.

RESULTS

This training model allows the use of a choledochoscope for transcystic exploration of the biliary tree. It combines fidelity and reproducibility required for a simulated training model to offer experience in laparoscopic transcystic common bile duct exploration. Validation of the model was demonstrated by 21 surgeons who completed a questionnaire after performing the simulated procedure. In all sections assessing reliability, face validity and content validity of the model, mean rating scores were between 4 and 5 out of five (good or excellent).

CONCLUSIONS

We present the evolution of an established training model for laparoscopic common bile duct exploration which focusses the attention on the transcystic approach to the common bile duct and the use of lithotripsy techniques. The need for such a model reflects the shift in the current practice of the laparoendoscopic management of choledocholithiasis with concomitant gallstones from transductal to transcystic approach.

The ABCdE score for PREdicting Lithotripsy Assistance during transcystic Bile duct Exploration by Laparoendoscopy (PRE-LABEL)

BACKGROUND

Common bile duct (CBD) stones are reported in ~ 15% of patients who undergo laparoscopic cholecystectomy for symptomatic gallstones. Prior to lithotripsy techniques, transcystic laparoscopic common bile duct exploration (LCBDE) was limited to smaller CBD stones. The addition of lithotripsy to LCBDE increases cost, operative time and staffing requirements. Predicting which patients might require lithotripsy would be useful in operative planning. The primary aim was to investigate clinical variables for predicting lithotripsy assistance during transcystic bile duct exploration by laparoendoscopy (PRE-LABEL). Secondary aims were to develop and validate a predictive scoring tool.

METHODS

A retrospective review of a prospectively collected database of consecutive patients who underwent transcystic LCBDE at a single centre in the UK was performed to investigate clinical variables for PRE-LABEL and develop a scoring tool (ABCdE score: age, bilirubin, CBD diameter, ERCP). Binary logistic regression was used to investigate which independent variables (predictors) were associated with lithotripsy assistance during transcystic LCBDE. The ABCdE score was applied to both UK and Spain patient cohorts to determine its sensitivity, specificity and accuracy.

RESULTS

From 8 pre-operative clinical variables analysed, age ≤ 40 years, bilirubin > two-times upper limit of normal, CBD diameter ≥ 10 mm and ERCP failure of stone extraction were independent predictors of requiring lithotripsy during transcystic LCBDE and formed the ABCdE score. The hazard ratios were 2.87, 3.79, 2.78 and 10.06, respectively. An ABCdE score ≥ 2 resulted in 71% sensitivity, 81% specificity and 79% accuracy in predicting lithotripsy during LCBDE (UK cohort). Validation using a contemporary cohort from Spain yielded similar sensitivity, specificity and accuracy.

CONCLUSIONS

This study represents the only study to date reporting independent predictors of requiring lithotripsy assistance during transcystic LCBDE. ABCdE score ≥ 2 can highlight patients that may require lithotripsy in order to avoid failure of transcystic LCBDE and therefore avoid choledochotomy or post-operative ERCP.

Laparoscopic transcystic common bile duct exploration (LTCBDE): a safer method to treat common bile duct stones than laparoscopic choledochotomy

We read the article published in the Spanish Journal of Gastroenterology and its accompanying editorial about the laparoscopic treatment of both cholecystolithiasis and choledocholithiasis in a single stage procedure. We would like to make some comments. Common bile duct (CBD) stones can lead to serious complications such as cholangitis and pancreatitis. So far, there is no standard surgical treatment for choledocholithiasis. Although, there are some ways to deal with CBD stones. Each method has its own advantages and disadvantages. In the era of advancements in minimally invasive technology, the treatment of CBD stones still remains controversial with regard to endoscopic retrograde cholangiopancreatography (ERCP) or laparoscopic common bile duct exploration (LCBDE). Preoperative ERCP followed by laparoscopic cholecystectomy (LC) is frequently performed.

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.

Laparoscopic common bile duct exploration in patients with previous abdominal biliary tract operations

BACKGROUND

A history of abdominal biliary tract surgery has been identified as a relative contraindication for laparoscopic common bile duct exploration (LCBDE), and there are very few reports about laparoscopic procedures in patients with a history of abdominal biliary tract surgery.

METHODS

We retrospectively reviewed the clinical outcomes of 227 consecutive patients with previous abdominal biliary tract operations at our institution between December 2013 and June 2019. A total of 110 consecutive patients underwent LCBDE, and 117 consecutive patients underwent open common bile duct exploration (OCBDE). Patient demographics and perioperative variables were compared between the two groups.

RESULTS

The LCBDE group performed significantly better than the OCBDE group with respect to estimated blood loss [30 (5-700) vs. 50 (10-1800) ml; p = 0.041], remnant common bile duct (CBD) stones (17 vs. 28%; p = 0.050), postoperative hospital stay [7 (3-78) vs. 8.5 (4.5-74) days; p = 0.041], and time to oral intake [2.5 (1-7) vs. 3 (2-24) days; p = 0.015]. There were no significant differences in the operation time [170 (60-480) vs. 180 (41-330) minutes; p = 0.067]. A total of 19 patients (17%) in the LCBDE group were converted to open surgery. According to Clavien's classification of complications, the LCBDE group had significantly fewer postoperative complications than the OCBDE group (40 vs. 57; p = 0.045). There was no mortality in either group. Multiple previous operations (≥ 2 times), a history of open surgery, and previous biliary tract surgery (including bile duct or gallbladder + bile duct other than cholecystectomy alone) were risk factors for postoperative adhesion (p = 0.000, p = 0.000, and p = 0.000, respectively).

CONCLUSION

LCBDE is ultimately the least invasive, safest, and the most effective treatment option for patients with previous abdominal biliary tract operations and is especially suitable for those with a history of cholecystectomy, few previous operations (< 2 times), or a history of laparoscopic surgery.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

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.

T-tube-free single-incision laparoscopic common bile duct exploration plus cholecystectomy: a single centre experience

BACKGROUND

The present study aimed to explore the indications and feasibility of T-tube-free trans-umbilical single-incision laparoscopic common bile duct exploration (SILCBDE) plus laparoscopic cholecystectomy (LC) for treating choledocholithiasis.

METHODS

Patients hospitalized in the Second Affiliated Hospital (Shengjing Hospital) of China Medical University from January 2010 to January 2017 with the diagnosis of common bile duct stones and treated with T-tube-free trans-umbilical single-incision LC plus common bile duct exploration were retrospectively analysed.

RESULTS

A total of 37 male/female choledocholithiasis patients (mean age 65 years, range 29-86) were treated with T-tube-free trans-umbilical SILCBDE plus LC. No intraoperative complication or conversion to open surgery occurred in any of the cases. The mean operative time was 99.8 min (range 84-125) for endoscopic nasobiliary drainage group (n = 6), 113.8 min (range 70-150) for endoscopic retrogradebiliary drainage group (n = 2), 131.1 min (range 75-161) for pigtail J-tube group (n = 24), 113.7 min (range 100-150) for primary closure group (n = 5). The mean post-operative hospital stay length was 5.5 days (range 4-7) for endoscopic nasobiliary drainage group, 12.5 days (range 10-15) for endoscopic retrogradebiliary drainage group, 6.5 days (range 4-10) for J-tube group, 5.8 days (range 4-9) for primary closure group. Pancreatitis, bile leakage and peritonitis were not presented in any of the group. After 17-101 months follow-up, three patients presented recurrent common bile duct stones.

CONCLUSION

In selected cases, T-tube-free trans-umbilical SILCBDE plus LC is feasible and safe for experienced surgeons, and can achieve similar therapeutic effects as common LC plus common bile duct exploration procedures.