Laparoscopic exploration of common bile duct with primary closure versus T-tube drainage: a randomized clinical trial

Primary closure compared with T-tube drainage following laparoscopic common bile duct exploration among elderly patients with hepatolithiasis and/or choledocholithiasis: a comparative study using a propensity score matching

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) is commonly used for hepatolithiasis and/or choledocholithiasis, but the ideal method for common bile duct closure remains uncertain, especially for elderly patients (≥65 years). This study compared outcomes of primary closure versus T-tube drainage following LCBDE in elderly patients.

METHODS

Data from elderly patients undergoing LCBDE for hepatolithiasis and/or choledocholithiasis between May 2016 and December 2020 at two Vietnamese hospitals were analyzed. Patients were divided into groups A (T-tube drainage, n = 52) and B (primary closure, n = 57). Propensity score matching (PSM) was utilized to adjust for baseline characteristics, comparing short- and long-term outcomes between groups.

RESULTS

PSM yielded 56 matched patients. Pre-PSM, group A had longer operating times and hospital stays than Group B (p = 0.001). Group A had higher postoperative complications (17.9 % vs. 7.1 %) but was not statistically significant (p = 0.422). Group A also had more complex biliary stones. Post-PSM, Group B maintained shorter operating times and hospital stays. Regarding long-term results, stone recurrence rates were similar (5.8 % vs. 3.5 %, p = 0.668).

CONCLUSION

Primary closure following LCBDE is a safe and effective alternative to T-tube drainage for treating hepatolithiasis and/or choledocholithiasis in elderly patients.

Perioperative Outcomes and Feasibility of Single-Stage Laparoscopic Common Bile Duct Exploration (LCBDE) and Cholecystectomy With Internal Endo-Biliary Drainage for Management of Concomitant Cholelithiasis With Choledocholithiasis: A Report From a Tertiary Care Hospital

INTRODUCTION

Managing choledocholithiasis alongside cholelithiasis has seen significant evolution, presenting options such as single-stage cholecystectomy with common bile duct (CBD) exploration, or a two-stage procedure involving endoscopic retrograde cholangiopancreatography (ERCP) performed before or after cholecystectomy. Evidence from Western settings may not fully capture the unique disease burden and demographic characteristics prevalent in developing countries. Laparoscopic common bile duct exploration (LCBDE) is more commonly performed in the Indian subcontinent compared to Western centers due to limited access to advanced procedures and specialized instrumentation for complex ERCP cases. The high cost and the need for extensive armamentarium in managing failed ERCPs make LCBDE a more feasible option in many Indian centers.

METHODS

This prospective study, conducted from August 2019 to July 2020 at King George's Medical University, UP, India, included n = 24 patients diagnosed with choledocholithiasis. The operative procedures performed included laparoscopic CBD exploration and cholecystectomy, along with internal endo-biliary drainage. Perioperative outcomes were assessed, and follow-up data were included to monitor any recurrence until 36 months post-surgery.

RESULTS

The study population had a mean age of 42.2 years, with 83% (n = of the patients being female). Abdominal pain was the predominant symptom, reported by 91.66% of the patients, followed by nausea/vomiting in 79.20% of cases. The mean CBD diameter observed was consistent with existing literature. The mean operating time was 2.02 h, with primary duct closure taking an average of 13.66 min. Mean blood loss during surgery was 136.25 mL. The average hospital stay was 5.54 days, with the majority of drain removals occurring by the third postoperative day. Complications included fever in 25.0% of the patients and bile leakage in n = 3 out of 24 cases (~12.50%). During the follow-up period, one patient (4.17%) experienced a retained stone.

CONCLUSION

Laparoscopic CBD exploration with primary duct closure and internal biliary drainage appears to be a feasible approach, yielding satisfactory perioperative outcomes. However, further studies are required to firmly establish its superiority over alternative approaches within the Indian context.

Comparison of the therapeutic effects of three minimally invasive approaches for laparoscopic cholecystectomy combined with common bile duct exploration-- a 5-year retrospective analysis

OBJECTIVE

The aim of this retrospective study was to explore the indications for three minimally invasive approaches-T-tube external drainage, double J-tube internal drainage, and primary closure-in laparoscopic cholecystectomy combined with common bile duct exploration.

METHODS

Three hundred eighty-nine patients with common bile duct stones who were treated at the Second People's Hospital of Hefei between February 2018 and January 2023 were retrospectively included. Patients were divided into three groups based on the surgical approach used: the T-tube drainage group, the double J-tube internal drainage group, and the primary closure group. General data, including sex, age, and BMI, were compared among the three groups preoperatively. Surgical time, length of hospital stay, pain scores, and other aspects were compared among the three groups. Differences in liver function, inflammatory factors, and postoperative complications were also compared among the three groups.

RESULTS

There were no significant differences among the three groups in terms of sex, age, BMI, or other general data preoperatively (P > 0.05). There were significant differences between the primary closure group and the T-tube drainage group in terms of surgical time and pain scores (P < 0.05). The primary closure group and double J-tube drainage group differed from the T-tube drainage group in terms of length of hospital stay, hospitalization expenses, and time to passage of gas (P <0.05). Among the three groups, there were no statistically significant differences in inflammatory factors or liver function, TBIL, AST, ALP, ALT, GGT, CRP, or IL-6, before surgery or on the third day after surgery (P > 0.05). However, on the third day after surgery, liver function in all three groups was significantly lower than that before surgery (P<0.05). In all three groups, the levels of CRP and IL-6 were significantly lower than their preoperative levels. The primary closure group had significantly lower CRP and IL-6 levels than did the T-tube drainage group (P < 0.05). The primary closure group differed from the T-tube drainage group in terms of the incidences of bile leakage and electrolyte imbalance (P < 0.05). The double J-tube drainage group differed from the T-tube drainage group in terms of the tube dislodgement rate (P < 0.05).

CONCLUSION

Although primary closure of the bile ducts has clear advantages in terms of length of hospital stay and hospitalization expenses, it is associated with a higher incidence of postoperative complications, particularly bile leakage. T-tube drainage and double J-tube internal drainage also have their own advantages. The specific surgical approach should be selected based on the preoperative assessment, indications, and other factors to reduce the occurrence of postoperative complications.

Laparoscopic common bile duct exploration with primary closure is preferred for selected elderly individuals with choledocholithiasis

Background

Laparoscopic common bile duct exploration with primary closure (LCBDE-PC) exhibits more benefits than other surgeries for patients with choledocholithiasis. It remains unclear whether it is feasible for and beneficial to elderly individuals. This study aimed to clarify and stratify elderly patients who would benefit from LCBDE-PC.

Methods

A retrospective study of 1240 patients with choledocholithiasis who underwent laparoscopic procedures between 2011 and 2019 was conducted. Patients were divided into the young group (<65 years old, n = 708) and the elderly group (≥65 years old, n = 532). Perioperative outcomes were compared between the two groups.

Results

Laparoscopic common bile duct exploration with primary closure was successfully performed in 90.20% of the elderly and 94.20% of the young. No significant differences were observed between the two groups regarding reoperation, postoperative bile leakage, residual stones, drainage removal, and postoperative mortality. Compared with the young, the elderly had longer postoperative hospital stay (p = 0.035) and delayed postoperative eating time (p = 0.036) in the matched cohort. Independent risk factors for failed LCBDE-PC were preoperative pancreatitis (p = 0.018), year of the surgeon's experience (p = 0.008), preoperative C-reactive protein level (p = 0.034), preoperative total bilirubin (p = 0.021), impacted common bile duct (CBD) stones (p = 0.006), blood loss (p = 0.001), and edema of the CBD (p = 0.001). A novel nomogram for predicting failed LCBDE-PC in elderly individuals exhibited a sufficient discriminative ability according to the estimated area under the curve (AUC) of 0.869 (95% CI: 0.817-0.921, p < 0.01).

Conclusion

Laparoscopic common bile duct exploration with primary closure is safe, feasible, and effective for elderly individuals with choledocholithiasis. Elderly patients with a high risk of failed LCBDE-PC should be cautious of undergoing LCBDE-PC.

The Outcome and Safety in Laparoscopic Common Bile Duct Exploration with Primary Suture versus T-Tube Drainage: A Meta-Analysis

Background

Sometimes, after choledochotomy, the common bile duct is closed with T-tube drainage for several weeks to prevent postoperative complications such as biliary fistula and stricture. But there has been controversy over the advantages of primary suture versus T-tube drainage. The purpose of our meta-analysis in laparoscopic common bile duct exploration is to appraise the efficacy and safety of T-tube drainage and primary suture.

Methods

The literatures were searched by Web of Science, PubMed, Cochrane Library, OVID, and EMBASE between the year January 1, 2001 and February 28, 2021. Meta-analysis was performed by Stata 12.

Results

Fourteen studies with 1,549 patients (827 vs. 722) were included in our study. The primary suture group had significant lesser operative time (P ≤ 0.001), postoperative hospital stay (P ≤ 0.001), hospital expenses (P ≤ 0.001), intraoperative bleeding (P=0.001), and postoperative complications (P=0.006) than the T-tube drainage group. In postoperative bleeding (P=0.289), bile leakage (P=0.326), and bile duct stricture (P=0.750), there was no statistical difference. In the primary suture group, using single-arm synthesis, the bile leakage rate and the bile duct stricture rate were 0.07 vs. 0.04 and 0.00 vs. 0.00 in interrupted suture and continuous suture groups. The bile duct stricture rate was same in both groups, and the bile leakage rate was lower in the interrupted suture group. But the difference was not significant.

Conclusion

The primary suture group had several advantages, including lesser operative time, postoperative complications, intraoperative bleeding, postoperative hospital stay, and hospital expenses. In bile leakage and bile duct stricture, the difference between the two groups was not significant. In the primary suture group, interrupted suture and continuous suture groups had similar bile leakage rate and bile duct stricture rate.

Comparative study of three common bile duct closure techniques after choledocholithotomy: safety and efficacy

PURPOSE

T-tube drainage, primary closure, and biliary stenting are the common bile duct closure methods. There is great debate on the optimal duct closure technique after common bile duct exploration. This study aimed to assess the safety and efficacy of the three commonest common bile duct closure methods after common bile duct exploration for common bile duct stone for future generalization.

METHODS

In this analysis, 211 patients with common bile duct stone underwent common bile duct exploration from January 2016 to December 2020. The patients were divided according to common bile duct closure techniques into three groups, including the T-tube drainage group (63 patients), primary duct closure group (61 patients), and antegrade biliary stenting group (87 patients).

RESULTS

The incidence of overall biliary complications and bile leak were statistically significantly lower in the biliary stenting group than in the other two groups. Also, hospital stays, drain carried time, return to normal activity, re-intervention, and re-admission rates were statistically significantly lower in the biliary stenting group than in the other two groups. There were no statistically significant differences regarding operative and choledochotomy time, retained and recurrent stone, stricture, biliary peritonitis, cholangitis, and the cost among the three groups.

CONCLUSIONS

We state that the biliary stenting procedure should be the preferred first option for common bile duct closure after common bile duct exploration when compared with T-tube drainage and primary duct closure.

TRIAL REGISTRATION

ClinicalTrials.gov PRS (Approval No. NCT04264299).

A life-threatening complication of biliary peritonitis following T-tube removal: A case report and review of literature

Introduction and importance

The purpose of T-tubes is to induce inflammation around it in the common bile duct, forming a fibrous tract for drainage of bile. The leakage of bile into the peritoneum is a drastic complication following T-tube removal. A provisional diagnosis of choleperitoneum is established in the presence of persistent pain with guarding and rigidity. Imaging techniques can be used for the identification of biliary leakage. With most cases, patients recover with either conservative or surgical management.

Case presentation

We present you a 65 years old malnourished female with features of choleperitoneum immediately following T-tube removal and was planned for conservative management with constant monitoring in surgical intensive care unit. The patient deteriorated despite adequate treatment and went into septic shock which resulted into her demise.

Clinical discussion

Biliary peritonitis is not very uncommon but a life-threatening complication of T-tube removal. Poor nutritional status may also lead to delay in fistulous tract formation and there is a relative risk of biliary leakage during removal of T-tube. The use of a latex T-tube is more effective in mature tract formation and has less incidence of bile leakage. Seldinger's method, which involves using a wire to guide the removal of the T-tube, shows a significant reduction of biliary leakage.

Conclusion

The mortality in biliary peritonitis significantly rises in cases of infected bile. The adverse reaction following the removal of T-tube was 4.3% and about 3% were severe enough to be admitted to the hospital.

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Biliary peritonitis is not very uncommon but a life-threatening complication of T-tube removal.

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Malnourishment causes delayed tract formation and increases risk of bile leakage during T-tube removal.

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Seldinger's method for T-tube removal shows a significant reduction in biliary leakage.

Greater than or equal to 8 mm is a safe diameter of common bile duct for primary duct closure: single-arm meta-analysis and systematic review

Greater than or equal to 8 mm was often used as the safe diameter of primary duct closure (PDC) after laparoscopic common bile duct exploration (LCBDE) in previous studies, but it is impossible to verify the source of this safe diameter, and lack of evidence for the safe diameter of PDC. Hence, this study evaluates the incidence of postoperative complications by single-arm meta-analysis to demonstrate the feasibility of using 8 mm as the safe diameter of PDC, so as to provide reference for clinical selection. Eligible studies were searched by MEDLINE, the Cochrane Library, Embase, and Web of Science from January 1995 to May 2021, investigating eligible literature using PDC after LCBDE for methods of common bile duct closure. The single-arm meta-analysis was analyzed by "meta" package under R 4.0.5, and the pooled incidence of postoperative complications was calculated. Twelve literatures were enrolled in this single-arm meta-analysis including 792 patients. The pooled complications rate including total complications (13.1%, 95% CI 10.1-15.6%), total biliary duct-related complications (9.4%, 95% CI 7.4-11.6%), residual stones (1.3%, 95% CI 0.3-2.7%), bile leakage (5.1%, 95% CI 3.5-6.9%), postoperative pneumonia (2.1%, 95% CI 0.8-3.8%), postoperative acute pancreatitis (1.8%, 95% CI 0.2-4.3%), and stone recurrence (2.6%, 95% CI 1.1-4.4%). The clinical indication of PDC after LCBDE should follow that the diameter of common bile duct ≥ 8 mm as the safe diameter.

Primary closure versus T-tube drainage after laparoscopic common bile duct exploration in patients with non-severe acute cholangitis

Although the feasibility of T-tube drainage after emergency laparoscopic common bile duct exploration (LCBDE) has been reported, the safety and effectiveness of primary closure (PC) after LCBDE in patients with non-severe acute cholangitis (AC) remain uncertain. This study aimed to investigate the safety and feasibility of PC after LCBDE in patients with non-severe AC. Consecutive choledocholithiasis patients with non-severe AC who were treated with a laparoscopic approach at our institution between January 2014 and March 2021 were enrolled. These patients were divided into two groups (PC group and T-tube group) based on the way of closure of the common bile duct. The baseline characteristics and perioperative data between the two groups were compared. A total of 230 patients who underwent LCBDE met the inclusion criteria, and there were 94 patients in the PC group and 126 patients in the T-tube group. Baseline data were balanced between the two groups, except that there was less acute cholecystitis in the PC group than in the T-tube group (P = 0.027). Compared to the T-tube group, the PC group had a shorter operation time (P < 0.001), less estimated blood loss (P < 0.001), less use of electrohydraulic lithotripsy (EHL) (P = 0.001), shorter time of drainage removal (P < 0.001) and postoperative hospital stay (P < 0.001) and residual stones (P = 0.029). There was no significant difference between the two groups in terms of conversion (4.3 vs. 4.4%, P = 1.000), intraoperative transfusion (0.0 vs. 0.7%, P = 1.000), use of basket (71.2 vs. 69.9%, P = 0.816), postoperative bleeding (1.1 vs. 0.7%, P = 1.000), biliary leakage (4.3 vs. 3.7%, P = 1.000), incision infection (1.1 vs. 2.2%, P = 0.649), pneumonia (2.1 vs. 1.4%, P = 1.000), or cholangitis (1.1 vs. 2.9%, P = 0.651). No postoperative mortality occurred in either group. During the follow-up period, no biliary stricture occurred in the two groups, and two patients in the T-tube group were found to have stone recurrence. PC after LCBDE in choledocholithiasis patients with non-severe AC shows superior clinical outcomes to T-tube drainage in terms of the operation time, estimated blood loss, time of drainage removal, postoperative hospital stay, and residual stones. PC is a safe and feasible treatment for choledocholithiasis patients with non-severe AC after LCBDE.

3D Laparoscopic common bile duct exploration with primary repair by absorbable barbed suture is safe and feasible

BACKGROUND AND AIM

Endoscopic retrograde cholangiopancreatography (ERCP), with interval laparoscopic cholecystectomy (LC), is the most common treatment approach for common bile duct (CBD) stones. However, recent studies show that single-stage laparoscopic CBD exploration (LCBDE) is safe and feasible. Three-dimensional (3D) laparoscopy enhances depth perception and facilitates intracorporeal suturing. The application of 3D technology for LCBDE is emerging, and we report our case series of 3D LCBDE.

METHODS

We audited the 27 consecutive 3D LCBDE performed from July 2017 to January 2020. We have a liberal policy for magnetic resonance cholangiopancreatography (MRCP) in patients with deranged liver function tests (LFT). All CBD explorations were done through choledochotomy with a 5 mm flexible choledochoscope and primarily repaired with an absorbable barbed suture without a stent or T-tube.

RESULTS

The mean age of patients was 68 (range 44-91) years, and 12 (44%) were male. The indications for surgery were choledocholithiasis 67% (n=18), cholangitis 22% (n=6), and gallstone pancreatitis 11% (n=3). About 67% (n=18) had pre-operative ERCP. About 37% (n=10) had pre-operative biliary stent. Pre-operative MRCP was done in 74% (n=20), and the mean diameter of CBD was 14.5 mm (range 7-30). The median operative time was 160 (range 80-265) min. The operative drain was inserted in 18 patients. One patient each (4%) had a bile leak and a retained stone. There was no open conversion, readmission, or mortality.

CONCLUSION

3D LCBDE with primary repair by an absorbable barbed suture is safe and feasible.

RELEVANCE FOR PATIENTS

This paper emphasized that one stage LCBDE should be a treatment option which is comparable with two stage ERCP followed by LC to treat CBD stones. In addition, 3D technology and barbed sutures use in LCBDE are safe and useful.

Review of the Endoscopic, Surgical and Radiological Techniques of Treating Choledocholithiasis in Bariatric Roux-en-Y Gastric Bypass Patients and Proposed Management Algorithm

Choledocholithiasis in post-surgical bariatric Roux-en-Y gastric bypass patients presents a significant challenge secondary to altered anatomy. We aim to review the existing management options including either endoscopic, surgical, percutaneous or hybrid means. Current literature suggests reasonably successful cannulation rates for single- or double-balloon ERCP ranging from 50 to 70% and 63-83%, respectively. The hybrid technique of laparoscopic transgastric ERCP has gained popularity with success rates ranging from 90 to 100%. Conventional laparoscopic techniques like transcystic duct and transcholedochal bile duct exploration are still useful options (i.e. high success rates of 81-100% and 83-96%, respectively). The role of percutaneous transhepatic choledochography remains limited although it can help with rapid bile duct decompression. If feasible, treatment pathways should progress from least to more invasive options as required.

Laparoscopic common bile duct exploration with primary closure is beneficial for patients with previous upper abdominal surgery

BACKGROUND

Previous upper abdominal surgery (PUAS) is considered a contraindication to laparoscopic surgery. Whether LCBDE-PC is feasible and beneficial for patients with PUAS remains unclear. This study aimed to evaluate the feasibility and benefits of LCBDE-PC for patients with PUAS.

METHODS

From June 2011 to September 2019, 1167 patients who underwent laparoscopic procedures for choledocholithiasis were reviewed retrospectively. Perioperative outcomes were compared between patients with and without PUAS in un-matched and matched cohorts.

RESULTS

LCBDE-PC was performed successfully in 88.3% of patients with PUAS, and 92.5% of patients without PUAS (P > 0.05). Multivariate analysis showed that PUAS was not a risk factor that affected successful performance of LCBDE-PC. Although a higher rate of conversion to open surgery and longer operative time were observed in patients with PUAS, no significant differences were found between patients with and without PUAS in multivariate and propensity score analysis (P > 0.05). A predictive nomogram for LCBDE-PC failure was developed based on potential predictors from the least absolute shrinkage and selection operator (LASSO) regression model. Successful performance of LCBDE-PC was associated with operative time. A linear regression model for operative time showed impacted stone in the CBD and intraoperative laser use was the most important factor in determining the operative time.

CONCLUSION

LCBDE-PC is feasible and beneficial for patients with PUAS. However, patients with PUAS with a high possibility of LCBDE-PC failure from the nomogram and a longer operative time from the linear regression model should be cautious when undergoing LCBDE-PC.

Primary Closure Versus T-Tube Drainage Following Laparoscopic Common Bile Duct Exploration in Patients With Previous Biliary Surgery

Laparoscopic common bile duct exploration (LCBDE) has been recently introduced for management of CBD stone in patients with previous biliary surgery history. The aim of this study was to evaluate the safety and effectiveness of primary closure in patients with previous biliary surgery history compared to T-tube drainage. Eighty patients with previous biliary surgery history including laparoscopic cholecystectomy, open cholecystectomy, or open common bile duct exploration were enrolled in the retrospective study. The patients were divided into 2 groups according to the methods of choledochotomy closure. Group A: patients with primary closure after LCBDE (n = 51); group B: patients with T-tube drainage after LCBDE (n = 29). Group A exhibited a shorter postoperative hospital stay and lower hospitalization expenses compared to group B. There was no significant difference in conversion rate to open surgery, operating time, intraoperative blood loss, bile leakage rate, overall complication rate, and stone recurrence rate between the 2 groups. Biliary stricture was not observed in the 2 groups during the follow-up period. Primary closure following LCBDE is safe and effective for the management of CBD stones in patients with previous biliary surgery history.

Can T-tube drainage be replaced by primary suture technique in laparoscopic common bile duct exploration? A meta-analysis of randomized controlled trials

BACKGROUND

Although laparoscopic common bile duct exploration (LCBDE) is considered the best treatment and has the advantages of being minimally invasive for common bile duct (CBD) stones, the choice of T-tube drainage (TTD) or primary duct closure (PDC) after LCBDE is still controversial. Therefore, the aim of the study was to compare the superiority of PDC versus TTD after LCBDE for choledocholithiasis.

METHODS

All potential studies which compare the surgical effects between PDC with TTD were electronically searched for in PubMed, Web of Science, and the Cochrane library databases up to November 2019. Data synthesis and statistical analysis were carried out using RevMan 5.3 software.

RESULTS

In total, six randomized controlled trials with 604 patients (307 in the PDC group and 297 in the TTD group) were included in the current meta-analysis. As compared with the TTD group, the pooled data showed that PDC group had shorter operating time (WMD = -24.30; 95% CI = -27.02 to -21.59; p < 0.00001; I² = 0%; p < 0.88), less medical expenditure (WMD = -2255.73; 95% CI = -3330.59 to -1180.86; p < 0.0001; I² = 96%; p < 0.00001), shorter postoperative hospital stay (OR = -2.88; 95% CI = -3.22 to -2.54; p < 0.00001; I² = 60%; p < 0.03), and lower postoperative complications (OR = 0.49; 95% CI = 0.31 to 0.78; p = 0.77; I² = 0%; p = 0.003). There were no significant differences between the two groups concerning bile leakage (OR = 0.74; 95% CI = 0.36 to 1.53; p = 0.42; I² = 0%; p = 0.90) and retained stones (OR = 0.96; 95% CI = 0.36 to 2.52; p < 0.93; I² = 0%; p < 0.66).

CONCLUSIONS

LCBDE with PDC should be performed as a priority alternative compared with TTD for choledocholithiasis.

Primary duct closure combined with transcystic drainage versus T-tube drainage after laparoscopic choledochotomy

BACKGROUND

We compared the post-operative course and final outcome of primary duct closure combined with transcystic drainage with those of T-tube drainage.

METHODS

We retrospectively analysed 112 consecutive patients treated with laparoscopic choledochotomy for common bile duct stones between February 2014 and December 2017. Primary closure with transcystic drainage was performed in 59 patients (group A), and laparoscopic choledochotomy with T-tube drainage was performed in 53 (group B). The primary endpoints were morbidity, the bile drainage quantity, operative time, post-operative stay, time until return to work and post-operative complications.

RESULTS

The operation was successfully completed in all patients. The return to work period in group A was significantly shorter than that in group B (7.25 ± 1.27 versus 46.47 ± 3.86 days, P < 0.05). The average daily drainage was not significantly different between the two groups (P > 0.05). There was no significant difference in the operation time (133.75 ± 14.51 versus 132.21 ± 12.71 min) and duration of hospital stay (5.15 ± 1.23 versus 5.94 ± 0.95 days) between the two groups (P > 0.05). Bile leakage was seen in one T-tube removal patient. No complications were reported in group A. The patients were followed for 2 to 29 months (average: 10). Normal liver function and no stricture of the bile duct were detected with ultrasonography.

CONCLUSION

Primary closure of choledochotomy and subsequent transcystic drainage is a simple and less invasive procedure than T-tube placement.

Primary closure after laparoscopic common bile duct exploration is feasible for elderly patients: 5-Year experience at a single institution

OBJECTIVE

Laparoscopic common bile duct exploration (LCBDE) has been demonstrated safety and effective for patients with gallbladder stones and extrahepatic bile duct stones, however few studies reported its suitability for the treatment of elderly patients. Thus, our study aims to investigate the safety and feasibility of primary closure after LCBDE in the treatment of elderly patients.

METHODS

408 out of 499 patients with Gallbladder stones complicated with choledocholithiasis who were undergone LCBDE and primary closure were divided into two groups: Group A (<65 years old, n = 249) and Group B (≥65 years old, n = 159) and the related clinical data were compared and analyzed by statistical method.

RESULTS

Pre-operative American Society of Anesthesiologists (ASA) score of elderly patients was significantly higher than the younger patients (P < 0.05). In both groups, the positive rate of Choledocholithiasis and bile sludge at exploration, number of stones in CBD, utilization rate of Electro-hydraulic lithotripsy, estimated blood loss, successful duct clearance, the rate of postoperative bile leakage, postoperative bile duct stricture, reoperation, stone recurrence, and other postoperative complications showed no significant difference (p > 0.05). There were also no statistical differences between both groups in time to removal of drainage, postoperative hospital stay, readmission within 30 days and mortality (p > 0.05).

CONCLUSIONS

It is safe and feasible to treat the elderly patients with common bile duct stones under the premise of strict surgical indications, skilled laparoscopic procedures and accurate endoscopic suture techniques.

Human fibrin sealant reduces post-operative bile leakage of primary closure after laparoscopic common bile duct exploration in patients with choledocholithiasis

Context:

Primary closure of the common bile duct (CBD) without drainage is considered a suitable approach after laparoscopic CBD exploration (LCBDE); however, the risk of post-operative bile leakage is high. Up to now, it has not been clear whether human fibrin sealant can reduce post-operative bile leakage of the primary suture.

Aims:

In this study, we evaluated the role of human fibrin sealant in primary closure of the CBD after LCBDE.

Subjects and Methods:

Patients with choledocholithiasis who had undergone primary duct closure of the CBD after LCBDE were divided into two groups according to whether fibrin sealant was used.

Statistical Analysis Used:

Fisher's exact test or the Chi-square test was used for categorical variables to calculate frequencies and percentages between the groups. The Student's t-test was used to compare the means of the continuous variables between the groups.

Results:

The human fibrin sealant group had a lower rate of post-operative bile leakage compared to the other group (P < 0.05). There were no significant differences in additional parameters such as operative time, post-operative stay duration, time to drain removal, bile duct stenosis, acute allergic reaction and overall mortality.

Conclusions:

Human fibrin sealant can reduce post-operative bile leakage in primary closure of CBD after LCBDE in patients with choledocholithiasis.

Biliary tract exploration through a common bile duct incision or left hepatic duct stump in laparoscopic left hemihepatectomy for left side hepatolithiasis: which is better?: A single-center retrospective case-control study

Laparoscopic left hemihepatectomy (LLH) followed by biliary tract exploration is used to treat left-sided hepatolithiasis (LSH). The purpose of this study was to compare the efficacy of 2 methods of biliary tract exploration in LLH:biliary tract exploration through a common bile duct (CBD) incision (with T-tube drainage) or through the left hepatic duct (LHD) stump (without T-tube drainage).LSH patients (113 patients) were recruited retrospectively in our hospital from December 2008 to January 2016. To compare different methods of biliary tract exploration during LLH, the patients were divided into 2 groups: 41 patients underwent biliary tract exploration through the LHD stump (LHD group), and 72 patients underwent biliary tract exploration through a CBD incision (CBD group). Baseline characteristics, surgical outcomes, surgery-related complications, postoperative hospital stay (PHS) and long-term results were compared between the 2 groups.There was no unplanned reoperation in the 2 groups. One patient in the CBD group had a residual stone, which was removed by choledochoscopy 2 months postoperation. Two patients in the LHD group and 3 patients in the CBD group had bile leakage and were cured with abdominal drainage. There were no significant differences in the total operation time, incidence of residual stones and bile leakage between the 2 groups (P > .05). The PHS and the incidence of hypokalemia or hyponatremia in the LHD group were significantly lower than those in the CBD group (P < .05). T-tube-related complications occurred in 13.9% (10/72) of the CBD patients. The mean follow-up period was 37.2 ± 13.8 months. There were no significant differences in the incidence of recurrence stones or cholangitis (P > .05) between the 2 groups.Exploration of the biliary tract through the LHD stump without T-tube drainage is safe with satisfactory short- and long-term results for selected LSH patients.

Should T-Tube Drainage be Performed for Choledocholithiasis after Laparoscopic Common Bile Duct Exploration? A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) has been verified to be a comparatively effective treatment approach for uncomplicated choledocholithiasis, and it has been previously proposed that the primary duct closure (PDC) technique, in which the bile duct can directly be sutured in only 1 step compared with the T-tube drainage (TTD), can be deemed a choice after LCBDE; however, the conventional TTD performance is controversial in the minimally invasive surgery era. On the basis of the above-mentioned point, this meta-analysis was conducted to assess the different effects between TTD and PDC after LCBDE.

MATERIALS AND METHODS

In PubMed, EMBASE, and the Cochrane Library, literature search was conducted to screen out randomized controlled trials (RCTs) to compare PDC with TTD. The analyzed outcome variables included overall morbidity, biliary-specific morbidity (retained stones, biliary leak, biliary peritonitis), other morbidities, operating time, postoperative hospital stay, reintervention (surgery, endoscopy/radiology), and median hospital expenses.

RESULTS

In this meta-analysis, there are 4 RCTs qualifying for inclusion, including 396 patients in all (222 in PDC and 214 in TTD). With respect to postoperative overall morbidity (P<0.05), biliary peritonitis (P<0.05), surgery time (P<0.05), length of stay (P<0.05), and median hospital expenses (P<0.05), PDC presented remarkably better results than TTD (P<0.05). Statistically, no remarkable distinction was found between the 2 groups as to biliary-specific morbidity, retained stones, biliary leak, other morbidities, or reintervention (radiology/endoscopy, surgery).

CONCLUSIONS

In this meta-analysis, there was no evidence provided for clinical benefits of using TTD after LCBDE. Therefore, TTD should not routinely be performed after LCBDE. However, multicenter, large sample size, RCTs should be conducted to clarify this issue.

Learning curve for performing choledochotomy bile duct exploration with primary closure after laparoscopic cholecystectomy

BACKGROUND

Primary closure after laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration (LCBDE) is a safe and effective approach for treating cholecystolithiasis with choledocholithiasis. The aim of this study was to evaluate the learning curve of performing primary closure after LC+LCBDE.

METHODS

We retrospectively identified all patients who underwent primary closure after LC+LCBDE performed by a single surgeon from January 2009 to April 2015 in our institution, and analyzed preoperative, intraoperative, and postoperative data using the cumulative sum (CUSUM) analysis to evaluate the learning curve for this procedure.

RESULTS

Overall, there were 390 patients. The total postoperative complications rate was 7.2%, including bile leakage in 9 (2.3%) patients and retained common bile duct stone in 3 (0.8%) patients. The CUSUM operating time (OT) learning curve was best modeled by the equation: CUSUM_OT = 312.209 × procedure^0.599 × e^{(-0.011×procedure)} + 122.608 (R² = 0.96). The learning curve was composed of two phases, phase 1 (the initial 54 patients) and phase 2 (the remaining 336 patients). A significant decrease in the OT (116.8 ± 22.4 vs. 93.8 ± 17.8 min; p < 0.001) and complication rate (16.7 vs. 5.7%; p < 0.01) including the rate of bile leakage (7.4 vs. 1.5%; p < 0.01) and retained stone (3.7 vs. 0.3%; p < 0.01) was observed between the two phases. In addition, 20 patients had conversion to open surgery. Impacted stones were independently associated with conversion, as indicated by a multivariable analysis.

CONCLUSION

The data suggest that the learning curve of this procedure was achieved in approximately 54 cases. An impacted stone was the only risk factor that affected the conversion rate.

Safety and efficacy of a novel continuous incision technique for laparoscopic transcystic choledocholithotomy

INTRODUCTION

The purpose of this study was to evaluate the safety and efficacy of a novel continuous incision technique for the cystic duct and the bile duct over the orifice for laparoscopic transcystic choledocholithotomy (LTCL).

METHODS

LTCL was attempted in 103 consecutive patients from January 1998 to March 2015 and was successful in 96 patients. The cystic duct confluence was made by cutting upward from the orifice in 19 patients. The cystic duct was incised downward beyond the orifice to the bile duct in the other 77 patients. Both of these procedures involved LTCL.

RESULTS

LTCL was successful in 96 patients. It failed in seven patients because of large bile duct stones (BDS), left lateral entry of the cystic duct, or the cystic duct's small diameter. The success rates of LTCL were 98% (47/48), 96% (42/44), and 64% (7/11) for patients with BDS <10 mm, 10-20 mm, and ≥20 mm, respectively. The success rate for removing BDS <20 mm was significantly higher than the removal rate for BDS ≥20 mm (P < 0.0001). There was no significant difference between the incidences of complications associated with BDS ≥10 mm and with BDS <10 mm (P = 0.49). In those who underwent successful LTCL, complications occurred in 3 of 23 patients with failed preoperative duodenoscopic sphincterotomy and in 9 of the other 73 patients; the incidence of complications did not significantly differ between these groups (P = 0.93).

CONCLUSION

LTCL is safe and feasible for exploration of the bile duct and removal of BDS <20 mm.

Appropriate Patient Selection Is Essential for the Success of Primary Closure After Laparoscopic Common Bile Duct Exploration

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) is being increasingly used for management of common bile duct (CBD) stones. Primary CBD closure has been reported to have better short-term outcomes compared to T-tube placement. However, primary CBD closure cannot be performed in all patients.

AIM

This study aims to evaluate the short- and long-term outcomes of LCBDE with primary CBD closure in appropriately selected patients and compare them with T-tube drainage.

METHODS

Retrospective analysis of patients undergoing LCBDE in our department from June 2011 to October 2014 was performed. Primary closure was performed in 52 patients (group A), and a T-tube was placed in 33 patients (group B). Patient demographics, intraoperative findings, postoperative stay, complications, and long-term follow-up data were recorded and compared.

RESULTS

The mean operating time was much longer in group A compared to group B (113.92 vs. 95.92 min, p = 0.032). The overall complication rate (9.6 vs. 6.3%, p = 0.701) and hospital stay (4 vs. 5.11 days, p = 0.088) were similar in both groups. No patient required conversion to the open procedure. Bile leakage was more frequent in group A (5.78 vs. 0%, p = 0.279), but this was not statistically significant. All three patients with bile leakage were treated successfully by conservative measures and gradual drain withdrawal. On long-term follow-up, recurrent stones were detected in two patients in group A. No patient was found to develop CBD stricture.

CONCLUSION

LCBDE and primary CBD closure has excellent short- and long-term outcomes when performed in appropriately selected patients.

Five hundred consecutive laparoscopic common bile duct explorations: 5-year experience at a single institution

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) has gained wide popularity in the treatment of choledocholithiasis. Bile leakage remains a major cause of postoperative morbidity. The aim of this study was to report 5-year results of 500 LCBDEs and identify risk factors associated with bile leakage.

METHODS

Five hundred consecutive LCBDEs performed in one institution from September 2011 to June 2016 were reviewed. Patients' clinical data were retrospectively collected and analyzed. Univariable and multivariable analysis of bile leakage was performed by logistic regression.

RESULTS

We found stones (n = 388) or bile sludge (n = 71) in 459 patients (92%) on exploration, leaving 41 patients (8%) without stones. Operative time was 128 min in the first 250 LCBDEs, and this decreased to 103 min in the second 250 LCBDEs (P = 0.0004). Four hundred and eight (82%) procedures were completed with primary closure after choledochotomy; the rate of primary closure increased significantly in the second 250 patients compared with the first (88 vs 76%; P = 0.0005), whereas T-tube placement (2 vs 6%; P = 0.0225) and transcystic approach (7 vs 12%; P = 0.0464) decreased, respectively. Stone clearance was successful in 495 patients (99%). Overall morbidity was 5%, and bile leakage occurred in 17 patients (3.4%). Two patients died from bile leakage. The median follow-up was 24 months with stone recurrence occurred in two patients and bile duct stricture in one patient. Univariable analysis identified diameter of the common bile duct (CBD), stone clearance, and T-tube insertion as risk factors related to bile leakage. Multivariable analysis taking these three factors into account identified non-dilated CBD (risk ratio (RR) = 9.87; P = 0.007) and failure in stone clearance (RR = 11.88; P = 0.024) as significant risk factors.

CONCLUSIONS

Bile leakage following LCBDE is associated with diameter of the CBD and stone clearance. LCBDE would be safer in proficient laparoscopic surgeons with a careful selection of patients.

Intraoperative endoscopic nasobiliary drainage over primary closure of the common bile duct for choledocholithiasis combined with cholecystolithiasis: a cohort study of 211 cases

BACKGROUND

Endoscopic nasobiliary drainage (ENBD) was often used for preoperative biliary drainage in cases like cholangiocarcinoma or acute obstructive suppurative cholangitis, reports on endoscopic nasobiliary drainage (ENBD) over primary closure of the common bile duct (CBD) are limited. This study compares outcomes of laparoscopic cholecystectomy (LC) + laparoscopic CBD exploration (LCBDE) + intraoperative ENBD + primary closure of CBD with equivalent patients who underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP) and subsequent LC.

METHODS

From January 2013 to December 2015, 829 consecutive patients with choledocholithiasis combined with cholecystolithiasis underwent surgery in our department. 211 patients underwent LC + LCBDE + intraoperative ENBD + primary closure of CBD (group A) and 117 preoperative ERCP + subsequent LC (group B). A total of 501 patients (355 who underwent T-tube drainage and 146 who underwent transcystic exploration) were excluded from the analysis. Clinical records, operative findings, and postoperative follow-up were analyzed.

RESULTS

Age and sex distribution, comorbidity, presentations, CBD diameter, and size and number of stones were similar in the two groups, and there was no postoperative mortality. Duration of surgery in group A was shorter (83 vs. 104 min, P < 0.01), as was postoperative hospital stay (6 vs. 9 days, P < 0.01). Average operative expenditure in group A was less than that of group B ($ 3816 vs. $ 4015, P < 0.01). The success rate in group A was higher (100 vs. 91%, P < 0.01). Ten patients in group B converted to LCBDE. The postoperative complication rate was higher in group B but without significant difference (1.9 vs. 4.2%, P = 0.29). Median follow-up time was 24 (3-28) months (n = 302 patients). Two patients in group B reported residual stones.

CONCLUSION

LC + LCBDE + intraoperative ENBD + primary closure of CBD should have priority over preoperative ERCP + subsequent LC for choledocholithiasis combined with cholecystolithiasis.

Primary Closure Versus Biliary Drainage After Laparoscopic Choledocotomy: Results of a Comparative Study

INTRODUCTION

To evaluate the feasibility, safety, and short-term outcomes of primary closure (PC) and biliary drainage (BD), after the laparoscopic treatment of common bile duct (CBD) stones by choledocotomy.

PATIENTS AND METHODS

Between January 2009 and December 2014, 102 patients underwent laparoscopy for lithiasis of the CBD. Intraoperative cholangiography was systematically performed, followed by choledocoscopy, depending on the size of the CBD.

RESULTS

Eighty (78.4%) of the 102 patients underwent laparoscopic stone extraction by choledocotomy, and were assigned to 2 groups: PC (group A, n=25), and BD (group B, n=55). Groups A and B were comparable in terms of age (62.3±26.1 vs. 66.0±19.3 y; P=0.53), the percentage of women (72.0% vs. 76.4%; P=0.68), body mass index (25.9±6.1 vs. 26.9±4.4 kg/m; P=0.52), and CBD diameter (11.6±3.1 vs. 12.1±3.8 mm; P=0.59). The mean durations of surgery and of hospital stay were significantly shorter in group A: 179±38 versus 211±57 minutes (P=0.02) and 5.4±2.0 versus 8.4±3.2 days (P<0.001). Groups A and B were comparable in terms of serious postoperative morbidity (Clavien-Dindo scores of 3, 4, and 5): 2 versus 4 (P=1). In group B, bile drain removal was complicated by choleperitoneum in 3 cases.

CONCLUSIONS

With shorter durations of surgery and hospital stay, equivalent postoperative morbi-mortality, and an absence of the specific morbidity due to bile drainage, PC may be considered a safe and feasible option for the laparoscopic management of CBD stones by choledocotomy.

Laparoscopic transcystic choledochotomy with primary suture for choledocholith

Background and Objectives:

To investigate the possibility of extracting common bile duct (CBD) stones by laparoscopically inserting choledochoscope through the natural orifice of the cystic duct and a mini-incision on the CBD, and the safety of laparoscopic primary double-layer suture of the cystic duct and CBD.

Methods:

Laparoscopic transcystic choledochotomy and extraction of stones with primary suture was performed on 194 patients with gallbladder and CBD stones from October 1, 2009, through April 30, 2012. The cystic duct was left at a diameter of 1 to 1.5 cm after removal of the gallbladder. The duct was longitudinally cut at its ventral side to the confluence with the CBD, and the anterior wall of the CBD was also cut longitudinally. A choledochoscope was then inserted via the enlarged opening, and the stones were extracted from the CBD. Finally, the CBD and cystic duct were closed by continuous mucous layer suture and seromuscular Lembert suture, respectively. The cystic duct was ligated close to the CBD and an abdominal drainage tube was placed.

Results:

All surgical procedures were successfully performed. The caliber at the confluence between the cystic duct and the CBD was 0.3 to 0.8 cm (SD 0.4 ± 0.1 cm), and the mini-incision of the CBD was 0.1 to 1.1 cm (SD 0.3 ± 0.2 cm). Abdominal drainage lasted 3 to 5 days. Magnetic resonance cholangiopancreatography (MRCP) in 55 patients showed no abnormal change in the CBD diameter. Two patients had bile leakage. Another patient had intermittent abdominal pain and jaundice 5 to 7 days postoperatively, and the retained stones spontaneously passed. The postoperative hospital stay was 6 to 13 days (SD 8 ± 2.1 days). Observation of 176 patients (90%) lasting 1 to 30 months (SD 11 ± 8 months) showed no recurrent stones or stricture of the CBD.

Conclusion:

The surgical procedure of laparoscopic transcystic choledochotomy and extraction of stones with primary suture is feasible and safe.

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.

Treatment of gallbladder stone with common bile duct stones in the laparoscopic era

Background

Laparoscopic common bile duct exploration (LCBDE) for stone can be carried out by either laparoscopic transcystic stone extraction (LTSE) or laparoscopic choledochotomy (LC). It remains unknown as to which approach is optimal for management of gallbladder stone with common bile duct stones (CBDS) in Chinese patients.

Methods

From May 2000 to February 2009, we prospective treated 346 consecutive patients with gallbladder stones and CBDS with laparoscopic cholecystectomy and LCBDE. Intraoperative findings, postoperative complications, postoperative hospital stay and costs were analyzed.

Results

Because of LCBDE failure,16 cases (4.6%) required open surgery. Of 330 successful LCBDE-treated patients, 237 underwent LTSE and 93 required LC. No mortality occurred in either group. The bile duct stone clearance rate was similar in both groups. Patients in the LTSE group were significantly younger and had fewer complications with smaller, fewer stones, shorter operative time and postoperative hospital stays, and lower costs, compared to those in the LC group. Compared with patients with T-tube insertion, patients in the LC group with primary closure had shorter operative time, shorter postoperative hospital stay, and lower costs.

Conclusions

In cases requiring LCBDE, LTSE should be the first choice, whereas LC may be restricted to large, multiple stones. LC with primary closure without external drainage of the CBDS is as effective and safe as the T-tube insertion approach.

Primary closure and rate of bile leak following laparoscopic common bile duct exploration via choledochotomy

BACKGROUND

Choledocholithiasis is traditionally managed by endoscopic retrograde cholangiopancreatography or T-tube insertion following common bile duct exploration. This study examined the efficacy and safety of primary duct closure following laparoscopic common bile duct exploration (LCBDE) via choledochotomy.

METHODS

Between September 2011 and September 2013, 157 consecutive patients underwent LCBDE via choledochotomy.

RESULTS

Of 157 LCBDE procedures, 138 (87.9%) were successfully completed with primary closure of the choledochotomy. Eight patients (5.1%) underwent closure with T-tube drainage after choledochotomy and 11 patients (7.0%) were converted to open surgery. The biliary tree was free of stones at the end of surgery in 154 patients (98.1%). Postoperative bile leak occurred in 6 patients (3.8%). The median follow-up period was 18 (2-33) months, with no evidence of further bile duct stones or bile duct stricture in any patients. Univariable analysis revealed that successful duct clearance (p = 0.010) and diameter of the common bile duct (p < 0.001) were two significant risk factors for bile leak.

CONCLUSIONS

Primary duct closure following LCBDE is effective and safe for the management of choledocholithiasis. The postoperative bile leak rate may be low in skilled laparoscopic surgeons with a careful selection of patients.

Use of biliary stent in laparoscopic common bile duct exploration

INTRODUCTION

It is well supported in the literature that laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis has equal efficacy when compared to ERCP followed by laparoscopic cholecystectomy. Decompression after supra-duodenal choledochotomy is common practice as it reduced the risk of bile leaks. We conducted a prospective non-randomized study to compare outcomes and length of stay in patients undergoing biliary stent insertion versus T-tube drainage following LCBDE via choledochotomy.

METHODS AND PROCEDURES

The study involved 116 patients with choledocholithiasis who underwent LCBDE and decompression of the biliary system by either ante-grade biliary stent or T-tube insertion. A 7 French straight/duodenal curve biliary Diagmed™ stent (9-11 cm) was placed in 82 patients (Biliary Stent Group). T-tube insertion was used for 34 patients (T-tube group). The length of hospital stay and complications for the selected patients were recorded. All trans-cystic common bile duct explorations were excluded from the study.

RESULTS

The mean hospital stay for patients who underwent ante-grade biliary stent or T-tube insertion after LBCDE were 1 and 3.4 days, respectively. This is a statistically significant result with a p value of less than 0.001. Of the T-tube group, two patients required laparoscopic washout due to bile leaks, one had ongoing biliary stasis and one reported ongoing pain whilst the T-tube was in situ. A complication rate of 11.2%, this was a significant finding. There were no complications or concerns reported for the Biliary Stent Group.

CONCLUSION

Our results show that there is a significant reduction in length of hospital stay and morbidity for patients that have ante-grade biliary stent decompression of the CBD post laparoscopic choledochotomy when compared T-tube drainage. This implies that ante-grade biliary stent insertion is likely to reduce costs and increase overall patient satisfaction. We support the use of ante-grade biliary stent insertion during LCBDE when primary closure is not preferred.

Primary closure after laparoscopic common bile duct exploration versus T-tube

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) is now one of the main methods for treating choledocholithiasis accompanied with cholelithiasis. The objective of our study was to assess the safety and effectiveness of laparoscopic primary closure for the treatment of common bile duct (CBD) stones compared with T-tube drainage.

METHODS

Patients who underwent CBD stones were studied prospectively from 2002-2012 in a single center. A total of 194 patients were randomly assigned to group A (LCBDE with primary closure) with 101 cases and group B (LCBDE with T-tube drainage) with 93 cases. Intraoperative cholangiography and choledochoscopy were performed in all patients. Patient demographics, intraoperative findings, postoperative stay, complications, and hospital expenses were recorded and analyzed.

RESULTS

There was no mortality in the two groups. Four patients (3.96%) of group A were converted to open surgery, and three patients (3.23%) in group B. The mean operating time was much shorter in group A than in group B (102.6 ± 15.2 min versus 128.6 ± 20.4 min, P < 0.05). The length of postoperative hospital stay was longer in group B (4.9 ± 3.2 d) than in group A (3.2 ± 2.1 d). The hospital expenses were significantly lower in group A. Three patients experienced postoperative complications, which were related to the usage of the T-tube in group B. The incidences of overall postoperative complications were insignificantly lower in group A.

CONCLUSIONS

Laparoscopic primary closure of CBD is safe and effective for the management of CBD stones, and can be performed routinely as an alternative to T-tube drainage.

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.

Case-based review: bile peritonitis after T-tube removal

T-tube placement into the common bile duct (CBD) is most commonly performed after CBD exploration for cholelithiasis or repair of an iatrogenic CBD injury. Bile peritonitis occurring after T-tube removal is generally considered an exceedingly rare complication, which on occurrence necessitates urgent intervention. No clear guidance exists on the timing of T-tube removal and its relationship to the development of bile peritonitis. This study aimed to determine the incidence of bile peritonitis after T-tube removal, its relationship to the timing of removal and how knowledge of this can help the general surgeon.

Lithotomy using cholangioscopy via the left hepatic duct orifice versus the common bile duct in laparoscopic treatment of left-sided hepatolithiasis: a comparative study

OBJECTIVE

Laparoscopic hepatectomy is widely used in the surgical treatment of left-sided hepatolithiasis (LSH). Lithotomy using a cholangioscope usually is required for the treatment of concurrent right-sided hepatolithiasis or choledocholithiasis. The primary objective of this study was to evaluate the effectiveness and safety of gallstone elimination using cholangioscopy through the left hepatic duct (LHD) orifice versus the common bile duct (CBD).

PATIENTS AND METHODS

Eligible LSH patients (n=41) were scheduled for laparoscopic left lateral segmentectomy or left hemihepatectomy with intraoperative biliary exploration using cholangioscopy through the LHD orifice (LHD group, n=23) or the CBD (CBD group, n=18) at the discretion of patients. Laparoscopic T-tube insertion was performed in selected patients. Patients were regularly followed up at monthly intervals or more frequently in the presence of any symptom. The primary outcome measures included overall operative time, duration of the cholangioscopy procedure, volume of blood loss, length of hospital stay, and frequency of procedure-related complications.

RESULTS

The two groups were comparable in sex, age, symptoms, site of lesion, and gallstone comorbidities (P>.05). Of the 18 patients in the CBD group, 12 (66.7%) patients had a T-tube inserted in contrast to 1 (4.5%) patient in the LHD group. The two groups were comparable in cholangioscopy duration and volume of blood loss (P>.05), whereas the LHD group had a significantly shorter operative time than the CBD group (221.4 ± 58.6 minutes versus 171.2 ± 63.5 minutes; P<.05). The postoperative duration of hospitalization was significantly shorter in the LHD group than in the CBD group (7.5 ± 2.2 days versus 4.2 ± 1.9 days; P<.05). No patient showed any recurrence of gallstones or cholangitis during the follow-up period.

CONCLUSIONS

As an effective and safe technique that is comparable to choledochotomy, LHD cholangioscopy is a preferred alternative to choledochotomy in the laparoscopic treatment of LSH because it offers patients shorter operative duration and length of hospitalization.

Does laparoscopic approach impair T-tube-related sinus-tract formation?

PURPOSE

Postoperative morbidity after bile duct exploration with T-tube insertion is mainly related to tube removal and incomplete sinus-tract formation leading to serious complications. Laparoscopic surgery reduces abdominal adhesion formation and diminishes tissue trauma and inflammatory response to surgery, which is essential for sinus-tract formation. This study evaluates if complication rate of T-tube removal is increased after laparoscopic bile duct exploration.

METHODS

Between January 2004 and January 2011, 94 patients underwent a T-tube insertion following choledocolithotomy (44 and 50 patients in the laparoscopic and open surgery group, respectively). Epidemiological data, preoperative characteristics, day of tube removal, and morbidity rates were analyzed.

RESULTS

Global T-tube removal-related biliary complication rate was 14.9% (18.2% in the laparoscopic group vs. 12% in the open surgery group). Although the day of T-tube removal was significantly delayed, there was a slight increased incidence of biliary peritonitis requiring reintervention in the laparoscopic surgery group (6.9% vs. 2%).

CONCLUSIONS

We reveal that T-tube removal is associated with significant morbidity. There was no statistical difference between the laparoscopic and the open surgery group, although global biliary complications after tube removal were slightly increased and bile spillage was worse delimited when T-tube was inserted laparoscopically. Laparoscopic approach may diminish inflammatory response and adherence development and impair, and therefore sinus-tract formation.

T-tube drainage versus primary closure after laparoscopic common bile duct exploration

BACKGROUND

T-tube drainage may prevent bile leak from the biliary tract following bile duct exploration and it offers post-operative access to the bile ducts for visualisation and exploration. Use of T-tube drainage after laparoscopic common bile duct (CBD) exploration is controversial.

OBJECTIVES

To assess the benefits and harms of T-tube drainage versus primary closure after laparoscopic common bile duct exploration.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until April 2013.

SELECTION CRITERIA

We included all randomised clinical trials comparing T-tube drainage versus primary closure after laparoscopic common bile duct exploration.

DATA COLLECTION AND ANALYSIS

Two of four authors independently identified the studies for inclusion and extracted data. We analysed the data with both the fixed-effect and the random-effects model meta-analyses using Review Manager (RevMan) Analysis. For each outcome we calculated the risk ratio (RR), rate ratio (RaR), or mean difference (MD) with 95% confidence intervals (CI) based on intention-to-treat analysis.

MAIN RESULTS

We included three trials randomising 295 participants: 147 to T-tube drainage versus 148 to primary closure. All trials had a high risk of bias. No one died during the follow-up period. There was no significant difference in the proportion of patients with serious morbidity (17/147 (weighted percentage 11.3%) in the T-tube drainage versus 9/148 (6.1%) in the primary closure group; RR 1.86; 95% CI 0.87 to 3.96; three trials), and no significant difference was found in the serious morbidity rates (weighted serious morbidity rate = 97 events per 1000 patients) in participants randomised to T-tube drainage versus serious morbidity rate = 61 events per 1000 patients in the primary closure group; RR 1.59; 95% CI 0.66 to 3.83; three trials). Quality of life was not reported in any of the trials. The operating time was significantly longer in the T-tube drainage group compared with the primary closure group (MD 21.22 minutes; 95% CI 12.44 minutes to 30.00 minutes; three trials). The hospital stay was significantly longer in the T-tube drainage group compared with the primary closure group (MD 3.26 days; 95% CI 2.49 days to 4.04 days; three trials). According to one trial, the participants randomised to T-tube drainage returned to work approximately eight days later than the participants randomised to the primary closure group (P < 0.005).

AUTHORS' CONCLUSIONS

T-tube drainage appears to result in significantly longer operating time and hospital stay as compared with primary closure without any evidence of benefit after laparoscopic common bile duct exploration. Based on currently available evidence, there is no justification for the routine use of T-tube drainage after laparoscopic common bile duct exploration in patients with common bile duct stones. More randomised trials comparing the effects of T-tube drainage versus primary closure after laparoscopic common bile duct exploration may be needed. Such trials should be conducted with low risk of bias, assessing the long-term beneficial and harmful effects including long-term complications such as bile stricture and recurrence of common bile duct stones.

Is the end of the T-tube drainage era in laparoscopic choledochotomy for common bile duct stones is coming? A systematic review and meta-analysis

OBJECTIVE

This study aims to compare the efficacy and safety of T-tube free (TTF) versus T-tube drainage (TTD) after laparoscopic common bile duct exploration (LCBDE).

BACKGROUND

LCBDE has been proven to be an effective and preferred treatment approach for uncomplicated choledocholithiasis, and the appropriateness of T-tube placement after laparoscopic choledochotomy for common bile duct (CBD) stones is still under debate.

METHODS

A systematic literature search (PubMed, EMBASE, Science Citation Index, Springer-Link, and Cochrane Central Register of Controlled Trials) was performed. Postoperative complications were evaluated/graded according to the modified Clavien classification. Other variables extracted including primary closures of the CBDs and the associated assistant methods, T-tube types, and placement durations. Stratified and sensitivity analyses were performed both to explore heterogeneity between studies and to assess the effects of the study qualities.

RESULTS

A total of 956 patients from 12 studies were included. The pooled odds ratio for postoperative complications and biliary-specific complications in TTF was found to be 0.59 [95% confidence interval (CI), 0.38-0.91; P = 0.02], 0.62 (95% CI, 0.36-1.06; P = 0.08), respectively, when compared with TTD. Operative time and hospital stay were significantly decreased in the TTF group, with the pooled weighted mean differences being 18.84 minutes (95% CI, -27.01 to 10.67; P < 0.01) and 3.22 days (95% CI, -4.59 to 1.84; P < 0.01), respectively.

CONCLUSIONS

The results of this meta-analysis demonstrate that among patients undergoing laparoscopic choledochotomy for common bile duct stones, primary closure of the CBD alone is superior to TTD; however, there is no significant benefit in terms of primary duct closure with various internal or external drainage techniques. Further randomized controlled trials are eagerly awaited to prove these findings.

A randomized trial comparing the use of endobiliary stent and T-tube for biliary decompression after laparoscopic common bile duct exploration

PURPOSE

To compare the use of a biliary stent with T-tube for biliary decompression after laparoscopic common bile duct (CBD) exploration.

METHODS

Between September 2004 and March 2008, 60 patients undergoing laparoscopic CBD exploration for CBD stones were randomized to choledochotomy closure over either a biliary stent or a T-tube after CBD clearance. Patients at high risk for surgery and unremitting cholangitis requiring preoperative endoscopic biliary drainage were excluded.

RESULTS

There were 29 and 31 patients in the T-tube and stenting groups, respectively. The 2 groups were comparable with respect to their demographic profile and disease characteristics. Patients in the stent group had a significantly shorter operative time and postoperative stay with an earlier return to normal activity (P<0.0001).

CONCLUSIONS

Choledochotomy closure over a stent results in a shorter postoperative stay and an earlier return to normal activity compared with closure over a T-tube without any increase in morbidity.

Laparoscopic common bile duct exploration in patients with previous upper abdominal operations

Backgrounds/Aims

We aimed to to evaluate the feasibility of laparoscopic common bile duct exploration (LCBDE) in patients with previous upper abdominal surgery.

Methods

Retrospective analysis was performed on data from the attempted laparoscopic common bile duct exploration in 44 patients. Among them, 5 patients with previous lower abdominal operation were excluded. 39 patients were divided into two groups according to presence of previous upper abdominal operation; Group A: patients without history of abdominal operation. (n=27), Group B: patients with history of upper abdominal operation. Both groups (n=12) were compared to each other, with respect to clinical characteristics, operation time, postoperative hospital stay, open conversion rate, postoperative complication, duct clearance and mortality.

Results

All of the 39 patients received laparoscopic common bile duct exploration and choledochotomy with T-tube drainage (n=38 [97.4%]) or with primary closure (n=1). These two groups were not statistically different in gender, mean age and presence of co-morbidity, mean operation time (164.5±63.1 min in group A and 134.8±45.2 min in group B, p=0.18) and postoperative hospital stay (12.6±5.7 days in group A and 9.8±2.9 days in group B, p=0.158). Duct clearance and complication rates were comparable (p>0.05). 4 cases were converted to open in group A and 1 case in group B respectively. In group A (4 of 27 (14.8%) and 1 of 12 (8.3%) in group B, p=0.312) Trocar or Veress needle related complication did not occur in either group.

Conclusions

LCBDE appears to be a safe and effective treatment even in the patients with previous upper abdominal operation if performed by experienced laparoscopic surgeon, and it can be the best alternative to failed endoscopic retrograde cholangiopancreatography for difficult cholelithiasis.

Primary closure following laparoscopic common bile duct exploration combined with intraoperative cholangiography and choledochoscopy

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) has become one of the main options for treating choledocholithiasis associated with cholelithiasis. Our objective was to assess the short-term outcomes of patients undergoing laparoscopic primary closure of the common bile duct (CBD) compared with laparoscopic choledochotomy plus T-tube drainage.

METHODS

We retrospectively studied 137 patients undergoing primary closure following LCBDE (group A) compared with 102 cases with laparoscopic choledochotomy plus T-tube drainage (group B) between January 2007 and January 2010. Intraoperative cholangiography (IOC) and choledochoscopy were performed in all patients.

RESULTS

Three patients in group A (2.2%) were converted to open surgery and two (2.0%) in group B because of serious adherence. According to routine IOC, unexpected CBD stones were found in 16 cases (6.8%). The duration of the operation in group A was shorter than in group B (92.4 ± 15.2 vs. 125.7± 32.6 min, P < 0.05), as was length of postoperative stay (3.1± 2.4 vs. 5.7± 4.3 days, P < 0.05). Postoperative bile leakage occurred in six patients (4.5%) in group A and four cases (4.0%) in group B; all of the patients recovered after simple drainage without reoperation. Bile peritonitis was seen in one case after T-tube removal. The median follow-up was 26 months. There were no recurrences.

CONCLUSIONS

Laparoscopic primary closure of the CBD is safe and successful for the management of CBD stones. Application of IOC and choledochoscopy to ensure clearance of the CBD and careful suturing are essential for primary closure.

Primary closure versus T-tube drainage in laparoscopic common bile duct exploration: a meta-analysis of randomized clinical trials

PURPOSE

To compare the safety and effectiveness of primary closure with those of T-tube drainage in laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis.

METHODS

A comprehensive search was performed in the PubMed, EmBase, and Cochrane Library databases. Only randomized controlled trials comparing primary closure with T-tube drainage in LCBDE were considered eligible for this meta-analysis. The analyzed outcome variables included postoperative mortality, overall morbidity, biliary complication rate, biliary leak rate, reoperation, operating time, postoperative hospital stay, time to abdominal drain removal, and retained stone. All calculations and statistical tests were performed using ReviewerManager 5.1.2 software.

RESULTS

A total of 295 patients (148 patients with primary closure and 147 patients with T-tube drainage) from three trials were identified and analyzed. No deaths occurred in any of the trials. Primary closure showed significantly better results in terms of morbidity (risk ratio (RR), 0.51; 95% confidence interval (CI), 0.30 to 0.88), biliary complication without a combination of retained stone (RR, 0.44; 95% CI, 0.20 to 0.97), reoperation (RR, 0.16; 95% CI, 0.03 to 0.87), operating time (mean difference (MD), -20.72; 95% CI, -29.59 to -11.85), postoperative hospital stay (MD, -3.24; 95% CI, -3.96 to -2.52), and time to abdominal drainage removal (MD, -0.45; 95% CI, -0.86 to -0.04). Statistically significant differences were not found between the two methods in terms of biliary leak, biliary complication, and retained stones.

CONCLUSION

The current meta-analysis indicates that primary closure of the common bile duct is safer and more effective than T-tube drainage for LCBDE. Therefore, we do not recommend routine performance of T-tube drainage in LCBDE.

T-tube drainage of the common bile duct choleperitoneum: etiology and management

External drainage of the common bile duct by placement of a T-tube is a common practice after choledochotomy. This practice may result in the specific complication of bile peritonitis due to leakage after removal of the T-tube. This complication has multiple causes: some are patient-related (corticotherapy, chemotherapy, ascites), and others are due to technical factors (inappropriate suturing of the drain to the ductal wall, minimal inflammatory reaction related to some drain materials). The clinical presentation is quite variable depending on the amount and rapidity of intra-peritoneal spread of of bile leakage. Abdominal ultrasound (US), with US-guided needle aspiration and occasionally Technetium(99) scintigraphy are useful for diagnosis. Traditional therapy consists of surgical intervention including peritoneal lavage and re-intubation of the choledochal fistulous tract to allow for a further period of external drainage. When leakage is walled off and well-tolerated, a more nuanced and less invasive conservative therapy may combine percutaneous drainage with endoscopic placement of a trans-ampullary biliary drainage.

Comparison of Bile Drainage Methods after Laparoscopic CBD Exploration

Purpose

T-tube is a major procedure that prevents complication by biliary decompression, but which is accompanied by complications. Therefore, several procedures such as ENBD, PTBD, and antegrade biliary stent have been attempted, but with controversies as to which procedure is superior. Also, there are no standard procedures after laparoscopic CBD exploration. We performed this study to ascertain the most appropriate biliary drainage procedure after laparoscopic CBD exploration.

Methods

From March 2001 to December 2009, 121 patients who underwent Laparoscopic CBD exploration in Gunyang University were included for retrospective analysis. The patients were divided to 4 groups according to type of procedure, and we compared clinical parameters including age and gender, operation time, hospital stay, start of post-operative diet, and complications.

Results

There was no difference in age, gender, mean operation time, postoperative diet between the 4 groups. Hospital stay in the Stent group was shorter than T-tube group. There were 10 (7%) complications that occurred. Two 2 occurred in the T-tube, 3 in PTBD, and 5 in the Antegrade stent group. There were more complications in Stent group but no significant statistical difference. In 5 cases with remnant CBD stone, a total of 4 (3 PTBD, 1 Stent) was performed by endoscopic CBD stone removal. One T-tube case was removed easily by choledochoscopy through the T-tube. Three migrated and the impacted stents were removed by additional endoscopy. Perioperative biliary leakage (1) and peritonitis (1) post t-tube removal were resolved by conservative treatment.

Conclusion

T-tube appears to be an appropriate method to patients who are suspected to have remnant CBD stones. Multiple procedures may be performed on a case by case basis such as performing PTBD first in a suspected cholangitis patient.

Primary closure versus T-tube drainage after common bile duct exploration for choledocholithiasis

PURPOSE

The aim of this study was to evaluate the benefits and harms of primary closure versus T-tube drainage after common bile duct (CBD) exploration for choledocholithiasis.

METHODS

A literature search of MEDLINE (PubMed), EMBASE, and the Cochrane Library was done to identify randomized controlled trials assessing the benefits and harms of primary closure versus T-tube drainage after CBD exploration from Jan. 1990 to Apr. 2010. A meta-analysis was set up to distinguish overall difference between the primary closure and the T-tube drainage group.

RESULTS

There were statistically significant differences between groups: biliary complications (odds ratio (OR) 95% confidence interval (CI), 0.42 (0.19-0.92); P = 0.03), main complications (OR 95% CI, 0.46 (0.23-0.90); P = 0.02), operating time (weighted mean difference (WMD) 95% CI, -19.53 (-29.35 to -9.71); P < 0.0001), and hospital stay (WMD 95% CI, -4.16 (-7.07 to -1.24); P = 0.005) except peri-operative mortality (OR 95% CI, 0.83 (0.11-6.37); P = 0.86), residual stones (OR 95% CI, 0.70 (0.22-2.25); P = 0.55), and abdominal collections (OR 95% CI, 1.93 (0.34-10.76); P = 0.46). And the result of wound infection (OR 95% CI, 0.38 (0.14-1.02); P = 0.05) tended to favor the primary closure group.

CONCLUSION

The primary closure might be as effective as T-tube drainage after choledochotomy in the prevention of the development of post-operative complications.