Complications of biliary T-tubes after choledochotomy

Comparative analysis of minimally invasive approaches for gallbladder and common bile duct stones: combined endoscopic techniques vs. ERCP with laparoscopic cholecystectomy

Objectives

The combined technology of laparoscopy, choledochoscope and gastroscope was used in the treatment of gallbladder stones combined with common bile duct stones, which consists of laparoscopic cholecystectomy (LC), laparoscopic common bile duct exploration with primary closure (LCBDE-PC) and combined gastroscopic and choledochoscopic transabdominal nasobiliary drainage (GC-NBD). The clinical effects of the combined technology were evaluated based on hospital stay, hospital costs, postoperative complications, recurrence of stones, and overall patient satisfaction.

Methods

From July 2017 to December 2020, 206 patients with gallbladder stones combined with common bile duct stones were reviewed retrospectively. According to the surgical method, the patients were divided into Triple-Scope group (LC + LCBDE-PC + GC-NBD), (n = 38), ERCP + LC group [endoscopic retrograde cholangiopancreatography (ERCP) followed by LC], (n = 96) and T tube group (LC + LCBDE + T tube drainage), (n = 72). The differences in stone size, hospital stay, hospital cost, postoperative gallstone recurrence rate and postoperative complications were compared among three groups.

Results

No postoperative bile leak occurred in Triple-Scope group, and patients were discharged successfully, and the abdominal drain was removed around 3 days after surgery, and the nasobiliary drainage was removed around 5 days after surgery with a hospital stay of 9.5 ± 2.65 days. The length of hospital stay and hospital cost in the Triple-Scope group were lower than those in the ERCP + LC group (P < 0.01), but not significantly different from those in the T tube group (P > 0.05). The diameter of common bile duct and stone size were significantly larger in the Triple-Scope group and T-tube group than in the ERCP + LC group (P = 0.001; P = 0.004), and the recurrence rate of stones in the Triple-Scope group was not significantly different compared with those in the other two groups (P = 0.43).

Conclusions

For patients with gallbladder stones combined with common bile duct stones, the triple-scope combination is safe and effective with fast recovery, and it is worthy of clinical promotion and application.

Laparoscopic primary suture of the common bile duct in patients with common bile duct stones: a comparative analysis of two suturing methods in terms of safety, efficacy, and convenience with 16-month follow-up

BACKGROUND

Primary suturing of the common bile duct (CBD) is increasingly used in laparoscopic common bile duct exploration (LCBDE) for selected patients, though the optimal suturing method remains unclear. This study compares the efficacy of continuous versus interrupted sutures for primary CBD closure in patients with CBD stones.

METHODS

A retrospective analysis was conducted on 120 patients with CBD stones who underwent primary CBD closure at Yancheng First People's Hospital from October 2022 to December 2023. Data included demographics, hospital stay, complications, and follow-up outcomes. Of these, 69 received continuous sutures, and 51 received interrupted sutures.

RESULTS

No significant differences were found in age, gender, body mass index (BMI), CBD diameter, preoperative bilirubin levels, or stone residuals between groups. The incidence of postoperative fever, bile leakage, electrolyte disturbances, bleeding, wound infection, and CBD stricture was similar. Continuous suturing required less operative time than interrupted suturing (p < 0.01).

CONCLUSION

Both continuous and interrupted suturing techniques are safe and effective for CBD closure in selected patients, though continuous suturing is more time-efficient.

Innovative strategies in bile duct repair: Assessing efficacy and safety across varied graft techniques - A systematic review

Bile duct injuries (BDI) from surgical procedures pose significant clinical challenges, requiring precise interventions for optimal outcomes. This systematic review explores the utilization of grafts in the repair of bile duct injuries, aiming to gain insights from existing literature. Graft-based techniques show promise in improving postoperative outcomes, but their efficacy varies. A systematic search was conducted across PubMed, Science Direct, and Scopus following the PRISMA 2020 Checklist, focusing on studies published until February 19, 2024. The inclusion criteria involved research using grafts to treat bile duct injuries in pig, swine, or mini-pig models. Out of 2231 studies identified, eleven met the inclusion criteria. These studies evaluated various graft techniques, including autologous tissue with biodegradable stents, decellularized grafts, patches, prosthetic grafts, bacterial cellulose film, and heterogeneous materials. Each method had distinct advantages and limitations, particularly regarding postoperative outcomes and histological findings. This review highlights the need for further research to determine the most effective graft-based strategies for BDI repair and improve patient care.

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.

Clinical application of indocyanine green fluorescence imaging in laparoscopic cholecystectomy with common bile duct exploration and J-Tube drainage

BACKGROUND

Intraoperative and postoperative biliary injuries remain significant complications of laparoscopic common bile duct exploration (LCBDE). Indocyanine green (ICG) has been shown to significantly reduce injuries caused by intraoperative operational errors. We found that the J-tube can reduce postoperative strictures and injuries to the common bile duct. At this moment, we aim to analyze and compare the complications, efficacy, short-term outcomes, and feasibility of these two adjunctive tools for LCBDE.

AIM

To evaluate the efficacy of ICG fluorescence imaging In LCBDE and J-tube drainage for patients with common bile duct stones.

METHODS

We retrospectively collected the clinical case data of patients who were treated at the Hepatobiliary Surgery Department of the Third People's Hospital of Nantong, affiliated with Nantong University, from January 2016 to January 2021 due to gallbladder stones with choledocholithiasis and who underwent LCBDE combined with a primary suture and either J-tube or T-tube drainage. The patients were divided into groups: Traditional white-light laparoscopy + T-tube group (WL + T-tube), traditional WL + J-tube group, fluorescent laparoscopy + T-tube group (ICG + T-tube) and fluorescent laparoscopy + J-tube group (ICG + J-tube). The preoperative and postoperative clinical case data, laboratory examination data, and intraoperative and postoperative complications (including postoperative bile leakage, electrolyte disturbances, biliary peritonitis, and postoperative infections) and other relevant indicators were compared.

RESULTS

A total of 198 patients (112 males and 86 females) were included in the study, with 74 patients in the WL + T-tube, 47 in the WL + J-tube, 42 in the ICG + T-tube, and 35 in the ICG + J-tube. Compared with the other groups, the ICG + J had significantly shorter operation time (114 minutes, P = 0.001), less blood loss (42 mL, P = 0.02), shorter postoperative hospital stays (7 days, P = 0.038), and lower surgical costs (China yuan 30178, P = 0.001). Furthermore, patients were subdivided into two groups based on whether a T-tube or J-tube was placed during the surgery. By the third postoperative day, the aspartate transaminase, glutamic pyruvic transaminase, total bilirubin, and direct bilirubin levels were lower in the J-tube group than in the T-tube group (P < 0.001). At last, follow-up observations showed that the incidence of biliary strictures at three months postoperatively was significantly lower in the J-tube group than in the T-tube group (P = 0.002).

CONCLUSION

ICG fluorescence imaging in laparoscopic cholecystectomy with common bile duct exploration and J-tube drainage facilitates rapid identification of biliary anatomy and variations, reducing intraoperative bile duct injury, blood loss, surgery duration, and postoperative bile duct stenosis rates, supporting its clinical adoption.

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.

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.

The safety of not implementing endoscopic nasobiliary drainage after elective clearance of choledocholithiasis: a systematic review and meta-analysis

BACKGROUND

Endoscopic nasobiliary drainage (ENBD) is used as a drainage technique in patients with choledocholithiasis after stone removal. However, ENBD can cause discomfort, displacement, and other complications. This study aims to evaluate the safety of not using ENBD following elective clearance of choledocholithiasis.

METHODS

Relevant studies were identified by searching PubMed, Web of Science, EMBASE, EBSCO, and Cochrane Library from their inception until August 2023. The main outcomes assessed were postoperative complications and postoperative outcomes. Subgroup analyses were conducted based on study design types and treatment procedures.

RESULTS

Six studies, including three randomized controlled trials (RCTs) and three cohort studies, were analyzed. Among these, four studies utilized endoscopic techniques, and two employed surgical methods for choledocholithiasis clearance. The statistical analysis showed no significant difference in postoperative complications between the no-ENBD and ENBD groups, including pancreatitis (RR: 1.55, p = 0.36), cholangitis (RR: 1.81, p = 0.09), and overall complications (RR: 1.25, p = 0.38). Regarding postoperative outcomes, the subgroup analysis indicated that the bilirubin normalization time was longer in the no-ENBD group compared to the ENBD group in RCTs (WMD: 0.24, p = 0.07) and endoscopy studies (WMD: 0.23, p = 0.005), although the former did not reach statistical difference. There was also no significant difference in the length of postoperative hospital stay between the groups (WMD: -0.30, p = 0.60).

CONCLUSION

It appears safe to no- ENBD after elective clearance of choledocholithiasis.

Minimally Invasive Common Bile Duct Stone Management in Gastric Bypass Patients: Laparoscopic Common Bile Duct Exploration with Disposable Bronchoscope

BACKGROUND

Bariatric surgery patients may develop common bile duct stones, and the alterations in their anatomy present challenges in treating this condition. Methods such as laparoscopic bile duct exploration is impractical in many healthcare facilities, due to the absence of a choledochoscope. This study assesses the feasibility of laparoscopic exploration of the common bile duct using a disposable bronchoscope in these individuals.

METHOD

The study involved 32 participants who had undergone gastric bypass surgery. These participants presented with both bile duct stones and bile ducts exceeding 8 mm in diameter, diagnosed through either MRCP or cholangiography conducted during the surgery. Stone extraction was carried out through either choledotomy or transcystic routes using a disposable bronchoscope and endoscopic baskets.

RESULTS

The patients' ages ranged from 27 to 66 years, with a mean bile duct diameter of 11.6 mm (SD 3.1 mm). A 100% stone clearance rate was achieved for all patients. None of the patients required conversion to open surgery. No T-tubes were placed. One patient developed biloma and intra-abdominal abscesses, which were successfully treated with a percutaneous drain over the course of a week. No mortalities were recorded during the course of this study.

CONCLUSION

Our study results demonstrate that laparoscopic bile duct exploration is both feasible and safe in patients who have undergone gastric bypass surgery. The utilization of a disposable bronchoscope emerges as a practical and cost-effective alternative to a choledochoscope in this procedure.

Feasibility and safety of choledochotomy primary closure in laparoscopic common bile duct exploration without biliary drainage: a retrospective study

Common bile duct (CBD) exploration and T-tube drainage are the main surgical methods for the removal of bile duct stones (BDSs), which can now be completed by laparoscopy. However, the feasibility and safety of primary closure of the CBD (PCCBD) in laparoscopic CBD exploration (LCBDE) without biliary drainage are still uncertain. From January 1, 2021, to June 30, 2022, patients who were diagnosed with BDSs and underwent LCBDE and primary closure of the CBD without biliary drainage in our hospital were included. The clinical and prognostic data of the patients were retrospectively analyzed to determine the feasibility and safety of PCCBD in LCBDE without biliary drainage. Forty-nine patients successfully underwent PCCBD in LCBDE without biliary drainage. The operation time was 158.8 ± 50.3 (90-315,150) minutes, the bile duct suture time was 17.6 ± 4.46 (10-26, 18) minutes, the intraoperative blood loss volume was 70.4 ± 52.6 (5-200, 80) ml, the hospitalization cost was 28,141.2 ± 7011.3 (15,005.45-52,959.34, 26,815.14) CNY Yuan, the hospitalization time was 13.22 ± 5.16 (8-32, 12) days, and the postoperative hospitalization time was 7.31 ± 1.94 (3-15, 7) days. There were 3 cases of postoperative bile leakage (3/49, 6.12%), all of them healed by nonsurgical treatment. During the follow-up of 17.2 ± 11.01 (10-26, 17) months, no residual BDSs, biliary stricture or other complications classified as Clavien-Dindo grade I or higher occurred. For some selected patients who meet certain criteria, PCCBD in LCBDE without biliary drainage is feasible and safe and is more conducive to the rapid postoperative recovery of patients.

The short- and long-term outcome after the surgical management of common bile duct stones in a tertiary referral hospital

BACKGROUND

The removal of common bile duct stones by endoscopic retrograde cholangiopancreatography (ERCP) shows excellent results with low complication rates and is therefore considered a gold standard. However, in case of stones non-removable by ERCP, surgical extraction is needed. The surgical approach is still controversial and clinical guidelines are missing. This study aims to analyze the outcomes of patients treated with choledochotomy or hepaticojejunostomy for common bile duct stones.

METHODS

All patients who underwent choledochotomy or hepaticojejunostomy for common bile duct stones at a tertiary referral hospital over 11 years were included. The analyzed data contains basic demographics, diagnostics, surgical parameters, length of hospitalization, and morbidity and mortality.

RESULTS

Over the study period, 4375 patients underwent cholecystectomy, and 655 received an ERCP with stone extraction, with 48 of these patients receiving subsequent surgical treatment. ERCP was attempted in 23/30 (77%) of the choledochotomy patients pre/intraoperatively and 11/18 (56%) in hepaticojejunostomy patients. The 30-day major complication rate (Clavien-Dindo > II) was 1/30 (3%) in the choledochotomy group and 2/18 (11%) in the hepaticojejunostomy group. Complications after 30 days occurred in 3/30 (10%) patients and 2/18 (11%), respectively, and no mortality occurred.

CONCLUSION

ERCP should still be considered the gold standard, although due to low short- and long-term morbidity rates, choledochotomy and hepaticojejunostomy represent effective surgical solutions for common bile duct stones.

Complications of biliary stenting versus T-tube insertion after common bile duct exploration: A systematic review and meta-analysis

BACKGROUND

Complications following the insertion T-tube or stent after common bile duct exploration (CBDE) remain problematic in nowadays surgical era. Based on our knowledge, we did not find any meta-analysis intentionally evaluating the complications between both groups. At this moment, we aimed to analyze and compare both procedures' complications, efficacy, efficiency, and feasibility.

METHODS

We searched literature from four databases (EuroPMC, PubMed, Scopus, and ClinicalTrials.gov) up to June 2022 to compile the randomized controlled trials and pro-/retrospective cohort studies. Review Manager 5.4 was used to statistically analyze each outcome measured between biliary stenting and T-tube insertion.

RESULTS

Sixteen studies with 1,080 patients (534 biliary stents and 546 T-tube) were included for qualitative and quantitative analysis. The pooled risk ratio (RR) of the overall postoperative complications rate was significantly lower in the biliary stent group compared to the T-tube group 0.43 [95% confidence interval (CI) 0.23-0.80, p = 0.007]. In terms of the operation time, length of hospital stay, and readmission rate was also decreased in stenting as biliary drainage over T-tube placement 1.02 minutes [95% CI -1.53, -0.52, p < 0.0001], 1.96 days [95% CI -2.63, -1.29, p < 0.00001], and RR 0.39 [95% CI 0.15-0.97, p = 0.04], respectively.

CONCLUSIONS

Stenting as biliary drainage after CBDE was superior to T-tube insertion. A shorter operation time and hospital stay in biliary drainage resulted in a lower overall postoperative complication rate. Other influences, including the complexity and shorter learning curve, might also affect the superiority of biliary stenting.

Safety and Feasibility of Primary Closure Following Laparoscopic Common Bile Duct Exploration for Treatment of Choledocholithiasis

BACKGROUND

T-tube drainage following laparoscopic common bile duct (CBD) exploration may lead to T-tube displacement and water-electrolyte disorders, affecting patients' quality of life. In particular, biliary peritonitis may develop in a small number of patients after T-tube removal, requiring reoperation. This prospective cohort study was performed to investigate the safety and feasibility of primary closure following laparoscopic CBD exploration for the treatment of choledocholithiasis.

METHODS

Patients who were treated for choledocholithiasis by laparoscopic CBD exploration with primary closure from January 2019 to March 2022 comprised the PC group (n = 145). Patients who were treated for choledocholithiasis by laparoscopic CBD exploration with T-tube drainage during this period comprised the TD group (n = 153). Perioperative and follow-up outcomes were collected and statistically analyzed.

RESULTS

The TD and PC groups showed significant differences in the operation time (124.6 ± 40.8 vs. 106 ± 36.4 min, P = 0.000) and postoperative hospital stay (7.1 ± 2.6 vs. 5.9 ± 2.0 days, P = 0.000). No significant difference was observed in terms of blood loss, the ratio of conversion to laparotomy, and postoperative parameters. Preoperative albumin and total bilirubin levels were the risk factors of bile leakage after surgery. No patients developed CBD stricture or carcinogenesis, The rates of residual and recurrent stones in the TD and PC groups were 1.97% vs. 1.40% and 1.31% vs. 1.40%, respectively, with no significant difference (P = 1.000 for both).

CONCLUSIONS

Primary closure following laparoscopic CBD exploration is safe and feasible for selected patients with choledocholithiasis.

Biliary Tract Exploration After Laparoscopic Left-sided Hepatectomy: A Comparative Study of Left Hepatic Duct Orifice Versus Common Bile Duct Approach

BACKGROUND

Laparoscopic left-sided hepatectomy (LLH) and additional biliary tract exploration are effective methods to treat left-sided hepatolithiasis (LSH) combined with extrahepatic bile duct stones. Although biliary tract exploration through common bile duct (CBD) incision has been widely accepted, the safety and effectiveness of the left hepatic duct (LHD) orifice approach after LLH is still in debate.

METHODS

One hundred and forty-four patients with LSH who underwent LLH and biliary tract exploration in our institution from April 2014 to September 2021 were enrolled in the retrospectively study. They were divided into 3 groups: LHD group (n=67), CBD/T-tube group (n=58), and CBD/PC group (n=19). Patients' demographic characteristics, intraoperative, and postoperative outcomes were retrospectively analyzed.

RESULTS

LHD group exhibited a shorter operative time (202.8±42.2 vs. 232.7±47.5 min, P =0.000), time to first bowel movement (2.3±0.5 vs. 2.9±0.7 d, P =0.000) and postoperative hospital stay (7.5±2.1 vs. 9.8±5.2 d, P =0.001) compared with the CBD/T-tube group. The lithotomy time in the LHD group was significantly longer than that in the CBD/T-tube group (33.6±7.3 vs. 29.0±6.3 min, P =0.000) and CBD/PC group (33.6±7.3 vs. 28.7±3.7, P =0.006). Intraoperative blood loss, blood transfusion rate, initial stone clearance rate, and stone recurrence rate all had no significant differences between the 3 groups (all P >0.05). LHD group showed less rate of electrolyte imbalance than that of the CBD/T-tube group (3.0% vs. 19.0%, P =0.004) but it was equivalent to the CBD/PC group ( P >0.05). The type of biliary tract exploration (odds ratio: 5.43, 95% confidence interval: 0.04-0.95, P =0.032) as independent predictors of electrolyte imbalance. No reoperation and mortality occurred in the 3 groups. The conversion rate was comparable among 3 groups (1.5% vs. 1.7% vs. 0, all P >0.05). No significant difference in stone recurrence rate was seen (1.5% vs. 3.4% vs. 0, all P >0.05).

CONCLUSION

Biliary tract exploration through LHD orifice after LLH is a safe and effective treatment for selected patients with LSH, with an advantage over the T-tube drainage in the field of operative time, the incidence of electrolyte imbalance, recovery of gastrointestinal function, and postoperative hospital stay.

The clinical effect of primary duct closure and T-tube drainage: A propensity score matched study

BACKGROUND

Although laparoscopic common bile duct exploration (LCBDE) is considered a safe and effective method for the removal of bile duct stones, selecting primary duct closure (PDC) or T-tube drainage (TTD) following choledochotomy remains controversial. This study aims to explore the clinical effects of PDC and TTD after LCBDE.

METHODS

We retrospectively analyzed clinical data of 348 patients with choledocholithiasis treated with LCBDE from January 2016 to October 2020. All patients were divided into PDC (225 cases) and TTD (123 cases) groups. Propensity score matching (PSM) was performed. We compared operative parameters and outcomes.

RESULTS

After matching (n = 116/group), no significant difference was observed between the two groups (P > 0.05) regarding intra-abdominal infection, incision infection, bile leakage, and retained stones. In terms of operation time, intraoperative blood loss, postoperative hospital stay, postoperative exhaust time, postoperative antibiotic use time, and postoperative abdominal drainage time, PDC group was obviously superior to TTD group (P < 0.05).

CONCLUSION

Primary closure following LCBDE is considered a safe and effective alternative to T-tube drainage.

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.

•

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

•

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

•

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

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.

Primary closure after laparoscopic common bile duct exploration is safe and feasible for patients with non-severe acute cholangitis

BACKGROUND

The safety and feasibility of primary closure after laparoscopic common bile duct exploration (LCBDE) have been confirmed in elective settings. However, the suitability of primary closure after LCBDE in the treatment of patients with non-severe acute cholangitis in emergency settings remains unclear. The aim of the present study was to explore the safety and feasibility of LCBDE with primary closure in patients with non-severe acute cholangitis.

METHODS

Consecutive patients with choledocholithiasis combined with gallbladder stones treated by LCBDE with primary closure at our institution from January 2015 to April 2021 were retrospectively reviewed. These patients were divided into two groups: emergency group (patients with non-severe acute cholangitis) and elective group (patients without acute cholangitis). The demographic and perioperative data of the two groups were compared.

RESULTS

One hundred twenty-two patients received LCBDE combined with primary closure during this period, including 70 in the emergency group and 52 in the elective group. Baseline characteristics were balanced in both groups, except for higher levels of white blood cells (WBC), C-reactive protein (CRP), total bilirubin, alkaline phosphatase (ALP), and albumin in the emergency group. No postoperative mortality occurred in either group. Compared to the elective group, the emergency group had a longer operation time (P = 0.011), and more estimated blood loss (P < 0.001). No significant differences were found between the two groups in terms of conversion (2.9% vs. 0.0%, P = 0.507), use of baskets (84.2% vs. 78.8%, P = 0.481), use of electrohydraulic lithotripsy (EHL) (2.9% vs. 1.9%, P = 1.000), or postoperative hospital stay (P = 0.214). The incidence of postoperative complications was comparable between the two groups. During the follow-up period, none of the patients experienced biliary stricture, and 1 case of stone recurrence occurred in the elective group.

CONCLUSIONS

LCBDE with primary closure for choledocholithiasis patients with non-severe acute cholangitis has the equivalent efficacy and morbidity to elective surgery. Primary closure after LCBDE is a safe and feasible option for choledocholithiasis patients with non-severe acute cholangitis.

Laparoscopic Common Bile Duct Exploration with Gallbladder Preservation: An Innovative Technique for Primary Common Bile Duct Stones

Background: Primary common bile duct (CBD) stones can be treated with laparoscopic CBD exploration (LCBDE), during which cholecystectomy is routinely performed. For patients without gallstones, we have developed a new procedure, LCBDE with gallbladder preservation. The purpose of this study was to evaluate the management of LCBDE with gallbladder preservation at our institution. Methods: Retrospective analysis the clinical data of 105 patients with primary CBD stones. Demographic data, clinical characteristics, preoperative risk factors, and postoperative complications were evaluated. Results: All patients were divided into two groups depending on the presence of gallstones: the primary CBD stone coexistence gallstones group (Group A, n = 15) and the primary CBD stones absence gallstones group (Group B, n = 90). Complete stones clearance was achieved in all patients. There were no significant differences in postoperative complications rates and mortality between the two groups. The mean postoperative hospital stay was 3.2 days for Group A and 4.1 days for Group B (P = .03). Conclusion: This study found that LCBDE with gallbladder preservation can effectively and safely treat primary CBD stones without gallbladder stones.

Remote-controlled cholangiography injection device: first clinical study in China

BACKGROUND

X-ray cholangiography is of great value in the imaging of biliary tract diseases; however, occupational radiation exposure is unavoidable. Moreover, clinicians must manually inject the contrast dye, which may result in a relatively high incidence of adverse reactions due to unstable injection pressure. Thus, there is a need to develop a novel remote-controlled cholangiography injection device.

METHODS

Patients with external biliary drainage requiring cholangiography were included. A remote-controlled injection device was developed with three major components: an injection pump, a pressure sensor, and a wireless remote-control panel. Image quality, adverse reactions, and radiation dose were evaluated.

RESULTS

Different kinds of X-ray cholangiography were successfully and smoothly performed using this remote-controlled injection device in all patients. The incidence of adverse reactions in the device group was significantly lower than that in the manual group (4.17% vs. 13.9%, P = 0.001), and increasing the injection pressure increased the incidence of adverse reactions. In addition, the device helped operators avoid ionizing radiation completely.

CONCLUSIONS

With good control of injection pressure (within 10 kPa), the remote-controlled cholangiography injection device could replace the need for the doctor to inject contrast agent with good security and effectivity. It is expected to be submitted for clinical application.

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.

Primary duct closure versus T-tube drainage after laparoscopic common bile duct exploration: a meta-analysis

BACKGROUND AND AIMS: Laparoscopic common bile duct exploration (LCBDE) is considered a safe and effective method for the removal of bile duct stones. However, the choice of primary duct closure (PDC) or T-tube drainage (TTD) technique after LCBDE is still controversial. This study aimed to compare the safety and effectiveness of PDC and TTD after LCBDE. METHODS: Studies published before May 1, 2021 in PubMed, Web of Science, and Cochrane Library databases were searched to screen out randomized controlled trials (RCTs) and cohort studies to compare PDC with TTD. Meta-analyses of fixed effect and random effect models were performed using RevMan 5.3. RESULTS: A total of 1865 patients were enrolled in six RCTs and ten cohort studies. Regarding RCTs, the PDC group was significantly better than the TTD group in terms of operation time, total postoperative complications, postoperative hospital stay, and hospitalization expenses (all P<0.05). Based on cohort studies of the subgroup, the PDC group had shorter operation time, shorter postoperative hospital stay, less intraoperative blood loss, and limited total postoperative complications. Statistically, there were no significant differences in bile leakage, retained stones, stone recurrence, bile duct stricture, postoperative pancreatitis, other complications, or postoperative exhaust time between the TTD and PDC groups. CONCLUSIONS: Based on the available evidence, compared with TTD, PDC is safe and effective, and can be used as the first choice after transductal LCBDE in patients with choledocholithiasis.

Comparison of Primary Suture and T-Tube Drainage After Laparoscopic Common Bile Duct Exploration Combined with Intraoperative Choledochoscopy in the Treatment of Secondary Common Bile Duct Stones: A Single-Center Retrospective Analysis

Objective: To compare the safety and feasibility of T-tube drainage and primary suture after laparoscopy combined with choledochoscopy in the treatment of secondary choledocholithiasis. Methods: The clinical data of patients who underwent laparoscopic choledochoscopy combined with choledochoscopic common bile duct exploration (LCBDE) for secondary choledocholithiasis from June 2015 to June 2020 were analyzed retrospectively. According to the different treatment method of common bile duct (CBD) incision, the patients were divided into a T-tube drainage group and a primary suture group. The preoperative clinical characteristics, results of preoperative liver function tests (LFTs), LFTs on the first day after the operation and the fourth day after the operation, operation time, intraoperative bleeding, postoperative complications, and times of postoperative hospital stay were compared between the two groups. Results: There was no significant difference in preoperative clinical data, preoperative LFTs, and postoperative complications between the two groups (P > .05). However, primary suture demonstrated significant advantages (P < .05) in terms of the operation time, intraoperative blood loss, postoperative hospital stay, and other related factors. Bilirubin levels on the first day after the operation and the fourth day after the operation between the two groups suggested that T-tube drainage reduces bilirubin in the short term, but that long-term bilirubin draining is similar between the two strategies. Univariate and multivariate analyses showed that choledochal diameter less than 8 mm was an independent risk factor for bile leakage. Conclusions: Laparoscopy combined with intraoperative choledochoscopic CBD exploration is superior to T-tube drainage in terms of the operation time, intraoperative blood loss, and postoperative hospital stay. The ability of reducing bilirubin by traditional T-tube drainage is indeed better than that of primary suture in the early stage after operation, but there is no difference in long-term outcome between the two groups. Choledochal diameter ≤8 mm was an independent risk factor for bile leakage. To summarize, LCBDEs primary suture for secondary choledocholithiasis is safe and feasible.

Reinterventions following laparoscopic cholecystectomy and bile duct exploration. A review of prospective data from 5740 patients

Background

Complications following laparoscopic cholecystectomy (LC) and common bile duct exploration (CBDE) for the management of gallstones or choledocholithiasis impact negatively on patients’ quality of life and may lead to reinterventions. This study aims to evaluate the causes and types of reintervention following index admission LC with or without CBDE.

Methods

A prospectively maintained database of LC and CBDE performed by a single surgeon was analysed. Preoperative factors, difficulty grading and perioperative complications requiring reintervention and readmissions were examined.

Results

Reinterventions were required in 112 of 5740 patients (2.0%), 89 (1.6%) being subsequent to complications. The reintervention cohort had a median age of 64 years, were more likely to be females (p < 0.0023) and to be emergency admissions (67.9%, p < 0.00001) with obstructive jaundice (35.7%, p < 0.00001). 46.4% of the reintervention cohort had a LC operative difficulty grade IV or V and 65.2% underwent a CBDE. Open conversion was predictive of the potential for reintervention (p < 0.00001). The most common single cause of reintervention was retained stones (0.5%) requiring ERCP followed by bile leakage (0.3%) requiring percutaneous drainage, ERCP and relaparoscopy. Relaparoscopy was necessary in 17 patients and open surgery in 13, 6 of whom not resulting from complications. There were 5 deaths.

Conclusion

This large series had a low incidence of reinterventions resulting from complications in spite of a high workload of index admission surgery for biliary emergencies and bile duct stones. Surgical or endoscopic reinterventions following LC alone occurred in only 0.8%. The most common form of reintervention was ERCP for retained CBD stones. This important outcome parameter of laparoscopic biliary surgery can be optimised through early diagnosis and timely reintervention for complications.

Horseshoe kidney leading to ERCP failure; innovative use of guide wire during laparoscopic CBD exploration: A case report

INTRODUCTION

Horseshoe kidneys are the most common fusion defect of the kidneys, which amounts to about 0.25% of the population. They are usually asymptomatic and are often identified incidentally. The horseshoe kidney can push the second and third part of the duodenum anteriorly, leading to an altered CBD course. Choledocholithiasis is seen in approximately 10-15% of patients with cholelithiasis. Presently, the most preferred approach for managing CBD stones is ERCP. However, in ERCP failure cases, Laparoscopic CBD exploration is the primary treatment modality, with or without T-tube use, with all the advantages of minimally invasive surgery.

CASE PRESENTATION AND DISCUSSION

A 65-year-old female presented with complaints of pain in the right hypochondriac region for three months associated with nausea, jaundice, and loss of appetite and weight. Her USG abdomen showed cholelithiasis with dilated CBD with horseshoe kidney with severe hydronephrosis of the left kidney. They are usually asymptomatic and are often identified incidentally. In this patient, it was believed that the horseshoe kidney had pushed the second and third part of the duodenum anteriorly, leading to an altered CBD course leading to ERCP failure. MRCP confirmed cholelithiasis with choledocholithiasis with dilated CBD of 11.3 mm with horseshoe kidney. ERCP was attempted but was unsuccessful due to non-visualization of the papilla due to overcrowding of duodenal folds. For patients with ERCP failure, laparoscopic CBD exploration is mandatory. For this patient, the CBD was cannulated with a guidewire, if needed, for repeat ERCP and was closed with T-tube in situ.

CONCLUSION

There are no particular preoperative indicators that can predict the failure of ERCP. However, in ERCP failure cases, laparoscopic CBD exploration (with or without T-tube use) is the primary treatment modality.

Primary Two-Layered Closure of the Common Bile Duct Reduces Postoperative Bile Leakage After Laparoscopic Common Bile Duct Exploration

Objective: The effectiveness and feasibility of the primary closure after laparoscopic common bile duct exploration (LCBDE) have been well demonstrated, however, the incidence of postoperative bile leakage after LCBDE remains high. The current study aimed at investigating whether our new suturing method could reduce the risk of bile leakage after LCBDE. Materials and Methods: This retrospective study included 81 patients who underwent primary two-layered closure or traditional primary closure of the common bile duct (CBD) after LCBDE, and the related clinical data were compared and analyzed. Results: The primary two-layered closure group had a lower rate of bile leakage compared with the traditional primary closure group (P < .05). There were no significant differences in additional parameters, such as operative time, estimated blood loss, postoperative stay duration, time to drain removal, postoperative pancreatitis, stone recurrence, and overall morbidity. No patients developed bile duct stenosis during the follow-up period. Conclusions: Primary two-layered closure of CBD can reduce the postoperative bile leakage after LCBDE. Moreover, it is a safe and effective therapeutic option for patients with choledocholithiasis.

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.

The Efficiency of Laparoscopic Common Bile Duct Exploration in Endoscopic Retrograde-Cholangiopancreatography-Limited Setting in a Peripheral University Hospital

Background: The aim of this study is to evaluate complications and costs in patients treated with laparoscopic and open method for common bile duct (CBD) stones. Secondary aim is to compare the effectiveness, safety, and outcomes of these methods. In addition, it is aimed to review the feasibility of laparoscopic method in rural areas. Methods: Seventy-one patients were analyzed retrospectively. Patients were divided into two groups as open and laparoscopic surgical method. These groups were analyzed comparatively in terms of complications and costs. Subgroups were formed from patients who underwent T-tube drainage, primary closure, and biliary anastomosis as choledochotomy management. As a secondary outcome, these three subgroups were investigated in terms of complications and cost. Results: The cost was lower in open method compared to laparoscopic method (484$, 707$, P = .002). There was no significant difference in postoperative complications between groups (P = .257). While the mean hospital stay was longer in the open group, the operation time was shorter (P = .002, P = .03). The mean length of hospital stay in the T-tube group was significantly higher than the primary closure (P = .001). The cost in the T-tube group was significantly higher than the primary closure and biliary anastomosis groups. Conclusion: Laparoscopic CBD exploration by experienced surgeons in endoscopic retrograde-cholangiopancreatography-limited settings is an effective and safe method in the treatment of choledocholithiasis. This procedure should not be limited to reference centers and should be performed safely in rural areas by well-trained surgeons.

Laparoscopic Common Bile Duct Exploration with Primary Closure for Management of Choledocholithiasis: A Retrospective Analysis and Comparison with Conventional T-tube Drainage

Laparoscopic common bile duct exploration (LCBDE) had become one of the main options for management of choledocholithiasis. This retrospective comparative study aimed to evaluate on the feasibility and advantages of primary closure versus conventional T-tube drainage of the common bile duct (CBD) after laparoscopic choledochotomy. In this retrospective analysis, 100 patients (47 men and 53 women) with choledocholithiasis who underwent primary closure of the CBD (without T-tube drainage) after LCBDE (Group A) were compared with 92 patients who underwent LCBDE with T-tube drainage (Group B). Both groups were evaluated with regard to biliary complications, hospital stay, and recurrence of stones. The mean operation time was 104.12 minutes for Group A and 108.92 minutes for Group B ( P = 0.069). The hospital stay was significantly shorter in Group A than that in Group B (6.95 days and 12.05 days, respectively; P < 0.001). In Group A, bile leakage occurred in two patients on postoperative Day 2 and Day 3, respectively. In Group B, bile leakage noted in one patient after removal of the T-tube on Day 14 after operation ( P = 1.000). With a median follow-up time of 40 months for both groups, stone recurrence was noted in two patients in Group A and three patients in Group B ( P = 0.672). Primary closure of the CBD is safe and feasible in selected patients after laparoscopic choledochotomy. It results in shorter duration of hospital stay without the need for carrying/care of a T-tube in the postoperative period and similar stone recurrence as that of the conventional method.

Safety and feasibility of laparoscopy technology in right hemihepatectomy

Laparoscopic hepatectomy (LH) has been accepted widely owing to its advantages as a minimally invasive surgery; however, laparoscopic right hemihepatectomy (LRH) has rarely been reported. We aimed to compare the benefits and drawbacks of LRH and open approaches. Between January 2014 and October 2017, 85 patients with tumor and hepatolithiasis who underwent LRH (n = 30) and open right hemihepatectomy (ORH) (n = 55) were enrolled in this study. For tumors, LRH showed significantly better results with respect to blood loss (P = 0.024) and duration of hospital stay (P = 0.008) than ORH, while hospital expenses (P = 0.031) and bile leakage rate (P = 0.012) were higher with LRH. However, the operative time and rate of other complications were not significantly different between the two groups. However, for hepatolithiasis, there was less blood loss (P = 0.015) and longer operative time (P = 0.036) with LRH than with ORH. There were no significant difference between LRH and ORH in terms of hospital stay, hospital expenses, and complication rate (P > 0.05). Moreover, the postoperative white blood cell count, alanine aminotransferase level, aspartate aminotransferase level, and total bilirubin were not significantly different in both types of patients (P > 0.05). Our results suggest the safety and feasibility of laparoscopy technology for right hemihepatectomy in both tumor and hepatolithiasis patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Primary closure with knotless barbed suture versus traditional T-tube drainage after laparoscopic common bile duct exploration: a single-center medium-term experience

Objective

Primary closure of the common bile duct (CBD) after laparoscopic CBD exploration (LCBDE) is a technical challenge. The present study was performed to evaluate the safety and effectiveness of this surgical method.

Methods

This retrospective study of surgical efficacy and safety involved 79 patients who underwent primary CBD closure with a knotless unidirectional barbed suture or traditional T-tube drainage after LCBDE for CBD stones.

Results

The average suturing time, operation time, and postoperative hospital stay were significantly shorter in the primary closure group than T-tube group. There were no significant differences in the mean diameter of the CBD, number of stones, or incidence of postoperative complications between the two groups. No patients developed recurrence of CBD stones during the median follow-up of 21.5 months.

Conclusions

After LCBDE and intraoperative choledochoscopy, primary closure with knotless unidirectional barbed sutures is a safe and effective therapeutic option for patients with cholelithiasis and concurrent CBD stones. This is especially true when the CBD is dilated more than 8 mm.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Advantages of laparoscopic left hemihepatectomy: A meta-analysis

BACKGROUND

Laparoscopic left hemihepatectomy (LLH) has been widely accepted as a minimally invasive alternative to open liver surgery. We assessed the benefits and drawbacks of LLH compared with open left hemihepatectomy (OLH) using meta-analysis.

METHODS

Relevant literature was retrieved using PubMed, Embase, Cochrane, and Ovid Medline databases. Multiple parameters of efficacy and safety were compared between the treatment groups. Results are expressed as odds ratio (OD) or mean difference (MD) with 95% confidence interval (95% CI) for fixed- and random-effects models.

RESULTS

The meta-analysis included 13 trials involving 1163 patients. Compared with OLH, LLH significantly reduced intraoperative blood loss (MD, -91.01; 95% CI, -139.12 to -42.89; P = .0002), transfusion requirement (OR, 0.24; 95% CI, 0.11-0.54; P = .0004), time to oral intake (MD, -0.80; 95% CI, -1.27 to -0.33; P = .0008), and hospital stay (MD, -3.94; 95% CI, -4.85 to -3.03; P < .0001). However, operative time; complications rate; and postoperative alanine transferase, albumin, and total bilirubin levels did not differ significantly between the 2 surgical groups (P > .05). For hepatolithiasis treatment, there were no significant differences in operative time, residual stones, stone recurrence, and complications rate between the groups (P > .05), but LLH resulted in lower incisional infection rate (OR, 0.44; 95% CI, 0.22-0.89; P = .02) than OLH. The LLH group demonstrated higher bile leakage rate (OR, 1.79; 95% CI, 1.14-2.81; P = .01) and incurred greater hospital costs (MD, 618.56; 95% CI, 154.47-1082.64; P = .009).

CONCLUSIONS

LLH has multiple advantages over OLH and should thus be considered as the first choice for left hemihepatectomy.

T-Tube Use After Laparoscopic Common Bile Duct Exploration

Background and Objectives:

Laparoscopic common bile duct exploration (LCBDE) has been verified to be an effective technique in treating choledocholithiasis, and T-tube insertion has been widely performed after LCBDE. With growing doubts regarding the effectiveness and safety of T-tube drainage (TTD), it has been suggested to replace such with primary duct closure (PDC). This meta-analysis aimed to evaluate the short- and long-term effectiveness and safety of PDC compared with TTD after LCBDE.

Methods:

The PubMed, Science Citation Index, and Cochrane Central Register of Controlled Trials databases were used to accomplish a systematic literature search for randomized controlled trials and pro-/retrospective cohort studies that compared PDC alone or PDC combined with biliary drainage stenting (PDC+BD) with TTD after LCBDE. A subgroup analysis was established to compare PDC+BD with TTD. RevMan 5.3 was used for the statistical analysis.

Results:

A total of 2552 patients from 26 studies were included. The pooled odds ratio supported PDC, which yielded lower postoperative overall morbidity and incidence of bile leak and bile peritonitis and shorter surgical time and postoperative hospital stay when compared with TTD. In the subgroup analysis, PDC+BD showed significantly better results in terms of postoperative overall morbidity, incidence of bile leak and bile peritonitis, surgical time, and postoperative hospital stay than did TTD. PDC and PDC+BD showed no difference in the incidence of recurrent stones and biliary stricture during the long-term follow-up period compared with TTD.

Conclusion:

PDC alone or PDC+BD is superior to TTD as a duct-closure method after LCBDE.

A Novel Remote-Controlled Injection Device for T-Tube Cholangiography: A Feasibility Study in Canines

Backgroun

The purpose of this study was to develop a remote-controlled injection device for T-tube cholangiography to avoid occupational exposure.

Material/Methods

The remote-controlled injection device has 3 major components: an injection pump, a pressure sensor, and a wireless remote-control panel. The feasibility and effectiveness of this device for T-tube cholangiography was evaluated in ex vivo porcine livers using a laparoscopic training platform and in in vivo canine experiments.

Results

The contrast dye was successfully injected into the biliary tracts of the ex vivo porcine liver and canines by the designed device. The X-ray images clearly showed the anatomical structure of the bile ducts. No obvious adverse reaction was observed in the dogs during or after the procedure. All steps were controlled remotely, avoiding ionizing radiation exposure to the surgeons.

Conclusions

This novel remote-controlled injection device for T-tube cholangiography can assist operators in completing cholangiography remotely and protecting them from occupational exposure.

The reasonable drainage option after laparoscopic common bile duct exploration for the treatment of choledocholithiasis

OBJECTIVE

To obtain a reasonable drainage after laparoscopic common bile duct exploration (LCBDE) for the treatment of choledocholithiasis.

METHODS

Data of 350 consecutive patients who underwent LCBDE in our hospital from January 2014 to December 2016 were retrospectively reviewed. All the patients were divided into three groups according to different drainage types after LCBDE, including T-tube group with 116 cases, primary closure (PC) group with 114 cases and stent insertion group with 120 cases. Operative parameters and outcomes were compared.

RESULTS

The operative time was no significant difference between the T-tube group (106.71 ± 5.19 min), PC group (105.46 ± 5.77 min) and stent insertion group (106.88 ± 5.91 min) (F = 2.175, P = 0.115). The postoperative hospital stay was significantly shorter in the stent insertion group (5.62 ± 0.70 d) than in the T-tube group (7.79 ± 0.85 d) and PC group (7.60 ± 0.80 d) (F = 279.649, P = 0.000). The hospitalization cost was significantly less in the stent insertion group (19,432.78 ± 661.74 yuan) than in the T-tube group (22,059.90 ± 697.98 yuan) and PC group (21,927.20 ± 772.02 yuan) (F = 512.492, P = 0.000). The incidence of postoperative biliary-specific complications was 2.59% (3/116 cases) in the T-tube group, 2.63% (3/114 cases) in the PC group, and 0% (0/120 cases) in the stent insertion group, but this difference was not statistically significant (χ² = 3.177, P = 0.204). The return to normal levels of postoperative liver function tests (LFTs) was significantly faster in the stent insertion group and T-tube group than in the PC group (P < 0.05). The number of 314 patients were followed up for a median time of 20 months (range from 1-48 months), and no biliary stricture, cholangitis or stone recurrence occurred in these patients during that time.

CONCLUSIONS

Stent insertion shows better results when compared with T-tube drainage and primary duct closure in terms of postoperative hospital stay and hospitalization cost. It is the prior option for the choledochotomy closure after LCBDE in suitable 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.

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

BACKGROUND

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

DATA SOURCES

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

RESULTS

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

CONCLUSION

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

Recurrent common bile duct stones as a late complication of endoscopic sphincterotomy

Background

Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) has become well established as a modality for the management of common bile duct stones (CBDS), especially in the setting of associated cholangitis. Our study aims to determine the rate of long term morbidity of recurrent CBDS post ES.

Methods

A retrospective analysis of patients who underwent ERCP and ES (ERCP+ES) was undertaken on a prospectively maintained database from 1998 to 2012 at the Northern Hospital, Melbourne. Primary CBDS were defined as those detected at least 6 months after complete clearance of the CBD. Prior cholecystectomy was a requirement for inclusion and patients with primary CBD stones in the setting of an intact sphincter were excluded.

Results

A total of 1148 patients underwent ERCP, of which 573 had an ES. Fifty-one patients underwent an ES prior to developing primary CBDS (8.9%). The time to recurrence ranged from 6 months to 15 years (mean 3.3 years). The number of procedures per patient ranged from 2 to 11, with 51% requiring 3 or more ERCPs. Factors associated with primary CBDS recurrence included a dilated CBD > 12 mm, stricture of the major papilla post ES to 2 - 5 mm and presence of the ampulla within or on the edge of a duodenal diverticulum.

Conclusion

The results demonstrate that ERCP + ES has an inherent long-term complication of recurrent primary CBDS formation. While this can be managed with repeat ERCP, the advent of laparoscopic bile duct exploration should lead us to re-examine the role of ERCP + ES in younger patients.

Laparoscopy-assisted micropercutaneous choledocholithotripsy with holmium laser in a cholecystectomized patient: an initial report

We present a novel minimally invasive technique, laparoscopy-assisted micropercutaneous choledocholithotripsy, for choledocholithiasis that cannot be treated with other endoscopic techniques. This technique includes standard laparoscopic exploration of the common bile duct, combined with an all-seeing needle and holmium laser lithotripsy. As is known, an all-seeing needle is used in micropercutaneous nephrolithotomy for middle-sized renal stones. In this technique, an all-seeing needle was inserted into the dilatated common bile duct under laparoscopic vision and then a lithotripsy procedure was performed with a holmium laser behind the biliary stent. A cholecystectomized female patient with a 21-mm stone in the common bile duct who previously underwent an unsuccessful endoscopic retrograde cholangiopancreatography procedure was operated on in our service with laparoscopy-assisted micropercutaneous choledocholithotomy without a T-tube. This novel procedure was completed uneventfully and the patient was discharged without any complications. In the future, this procedure will hopefully be a treatment modality in choledocholithiasis that cannot be treated by other minimally invasive techniques.