Laparoscopic Common Bile Duct Exploration Is a Safe and Effective Strategy for Elderly Patients

Risk factors for bile leakage after laparoscopic common bile duct exploration in older patients with choledocholithiasis

BACKGROUND

At present, there are few studies on the risk factors for bile leakage after laparoscopic common bile duct exploration (LCBDE) for older patients with choledocholithiasis.

AIM

To identify the potential risk factors for bile leakage after LCBDE in older patients.

METHODS

A retrospective, single-center observational analysis was performed on patients aged ≥ 70 years with choledocholithiasis treated by LCBDE who were admitted to our center between January 2011 and August 2022. The included patients were divided into non-bile leakage and bile leakage groups. Risk factors were determined by analyzing the observation indicators.

RESULTS

Seventy older patients with choledocholithiasis who underwent LCBDE were included. Univariate analysis showed that positive culture of bile bacteria was a risk factor for bile leakage after LCBDE (P < 0.05). We further analyzed the bile bacteria, and univariate analysis showed that Enterococcus faecalis (E. faecalis) (P < 0.05) and Pseudomonas aeruginosa (P < 0.05) were associated with an increased risk of postoperative bile leakage in older patients (P < 0.05). Multivariate analysis showed that E. faecalis was an independent risk factor for postoperative bile leakage in older patients (P < 0.05). The results of antibiotic sensitivity analysis showed that E. faecalis had 100% susceptibility to penicillin, ampicillin, linezolid, vancomycin, and furantoin.

CONCLUSION

E. faecalis-associated biliary tract infection is an independent risk factor for bile leakage after LCBDE in older patients with choledocholithiasis. We suggest coverage with antibiotics to which E. faecalis is sensitive.

Laparoscopic Common Bile Duct Exploration for Choledocholithiasis in the Elderly: A Systematic Review and Meta-Analysis

Introduction: Laparoscopic common bile duct exploration (LCBDE) is a well-established and effective minimally invasive surgical approach for managing choledocholithiasis. However, its safety in the elderly population is not well established. Therefore, this study compares surgery-related outcomes in elderly patients undergoing LCBDE. Methods: We systematically searched PubMed, Embase, and Cochrane Library for studies comparing elderly and young patients undergoing LCBDE. Binary outcomes were compared using odds ratios (ORs), with 95% confidence intervals (CIs). Heterogeneity was assessed with I2 statistics. Statistical analysis was performed using Software R, version 4.3.3. Results: Twelve studies comprising 3791 patients were included, of whom 1411 patients (37%) were from the elderly group. Elderly patients were associated with an increase in mortality (OR: 3.42; 95% CI: 1.08-10.85; P = .04; I2 = 0%), overall postoperative complications (OR: 1.60; 95% CI: 1.11-2.22; P = .01; I2 = 52%), and pneumonia (OR: 4.37; 95% CI: 2.00-9.55; P < .01; I2 = 0%) rates. However, there were no significant differences between groups in remnant stones (OR: 1.37; 95% CI: 0.70-2.68; P = .36; I2 = 0%) and recurrent stones (OR: 1.37; 95% CI: 0.64-2.95; P = .42; I2 = 0%) pancreatitis (OR: 0.98; 95% CI: 0.16-5.95; P = .98; I2 = 0%) and bile leakage (OR: 1.24; 95% CI: 0.75-2.07; P = .40; I2 = 0%). Conclusion: In this meta-analysis, elderly patients who underwent LCBDE experienced increased mortality, overall complications, and pneumonia rates compared with young patients. Furthermore, there were no significant differences between the groups in remnant and retained stones, pancreatitis, and bile leakage.

Lessons learned from implementing laparoscopic common bile duct exploration at a safety net hospital

BACKGROUND

Mounting evidence favors one-stage laparoscopic cholecystectomy with common bile duct exploration over endoscopic retrograde cholangiopancreatography with cholecystectomy for choledocholithiasis. However, laparoscopic cholecystectomy with common bile duct exploration remains underused. In 2020, our center initiated a laparoscopic cholecystectomy with common bile duct exploration program for choledocholithiasis. This study compares the experience and outcomes of laparoscopic cholecystectomy with common bile duct exploration compared with endoscopic retrograde cholangiopancreatography with cholecystectomy at a safety net hospital.

METHODS

This single-center, retrospective study analyzed data from 179 patients admitted with choledocholithiasis from 2019 to 2023. Demographics, preoperative investigations, intraoperative details, and postoperative outcomes were evaluated.

RESULTS

The study included 179 patients (55.6 ± 21.0 years, 66% female) with American Society of Anesthesiologists Physical Status Classification System score III (II-III) and body mass index 29 kg/m2 (25.8-35.5 kg/m2). Of these, 148 underwent endoscopic retrograde cholangiopancreatography with cholecystectomy and 31 underwent laparoscopic cholecystectomy with common bile duct exploration. Demographic and preoperative data were similar between groups. Laparoscopic cholecystectomy with common bile duct exploration achieved a 74.2% success rate. Laparoscopic cholecystectomy with common bile duct exploration's average operative time was 180 (139-213) minutes, with a 3.2% postoperative bile leak and 35.4% requiring postoperative ERCP. Median lengths of stay were 3 (1-4) for laparoscopic cholecystectomy with common bile duct exploration and 4 days (3-7) for endoscopic retrograde cholangiopancreatography with cholecystectomy (Z = -3.16, P = .002). The number of readmissions were 1.2 ± 0.4 for laparoscopic cholecystectomy with common bile duct exploration and 1.9 ± 1.3 for endoscopic retrograde cholangiopancreatography with cholecystectomy (t = 1.43, P = .08). Additional procedures for choledocholithiasis were performed in 36% of laparoscopic cholecystectomy with common bile duct exploration and 79% of ERCP + LC cases (χ2 = 21.7, P < .0001).

CONCLUSION

The study highlights challenges in implementing laparoscopic cholecystectomy with common bile duct exploration at a safety net hospital. Results support laparoscopic cholecystectomy with common bile duct exploration over endoscopic retrograde cholangiopancreatography, with cholecystectomy, with shorter stays, fewer readmissions, and fewer additional procedures reported. Laparoscopic cholecystectomy with common bile duct exploration remains underused, with only 17.3% of patients who underwent one-stage laparoscopic cholecystectomy with common bile duct exploration. Further research is needed for laparoscopic cholecystectomy with common bile duct exploration's expansion as the superior choledocholithiasis treatment.

Index admission vs elective laparoscopic common bile duct exploration: a district general hospital experience over 6 years

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) is relatively a new approach for clearing choledocholithiasis. The aim of this study is to assess the safety of this approach to clearing common bile duct (CBD) stones on an index admission including emergency setting.

METHODS

Retrospective data collection and analysis were carried out for 207 consecutive cases of LCBDE performed in Royal Cornwall Hospital over 6 years (2015-2020). Patients were divided into two groups (Index admission vs elective) then both groups compared.

RESULTS

A total of 207 cases of LCBDE were performed in our unit during the time period. One hundred twenty-two operations were performed on the index admission and 85 on a subsequent elective list. Mean operative time was 146 ± 64 min in the index admission group and 145 ± 65 min in the elective group (p = 0.913). Length of stay post-operatively was 3.3 ± 6.3 days in the index admission cases and 3.5 ± 4.6 days after elective cases. Successful clearance was achieved at the end of the operation in 116 patients in the index admission group, clearance failed in one case and negative exploration in 5 patients. In the elective group 83 patients had a successful clearance at the end of the operation, and 2 patients has had a negative exploration. Twelve patients (index admission group) and 8 patients of the elective cases required post-operative Endoscopic Retrograde Cholangiopancreatography (ERCP) to manage retained stones, recurrent stones and bile leak (p = 0.921). Three patients required re-operation for post-operative complications in each group.

CONCLUSION

Common bile duct exploration in index admission is safe with high success rate if performed by well-trained surgeons with advanced laparoscopic skills.

Is Laparoscopic Common Bile Duct Exploration Safe For The Oldest old patients?

Background

This study aimed to identify the risk factors for postoperative complications of laparoscopic common bile duct exploration (LCBDE) in the oldest old patients aged 80 years or older.

Methods

From March 2001 to October 2020, 363 patients underwent LCBDE with stone removal. Based on their ages, they were divided into two groups, those younger than 80 years (n=240) and those 80 years old or older (n=123). We compared patient demographics, disease characteristics, surgical outcomes, and postoperative complications based on these groups.

Results

The older group had a higher proportion of patients with a Charlson Comorbidity Index ≥5 (p<0.001) and the American Society of Anesthesiologist (ASA) physical status classification ≥3 (p<0.001). In addition, the older group had longer postoperative hospital stays than younger group (7.5±6.1 days vs. 6.2±3.9 days, p=0.013). However, there were no significant differences between groups according to the postoperative complications (13.8% vs. 20.3%, p=0.130). According to multivariate analysis, the risk factors for postoperative complications were Charlson Comorbidity Index ≥5 (odds ratio [OR]=2.307; 95% confidence interval [CI], 1.162–4.579; p=0.017) and operative time >2 hours (OR=3.204; 95% CI, 1.802–5.695; p<0.001).

Conclusion

In patients with Charlson Comorbidity Index <5 and operation time <2 hours, LCDBE with stone removal can be considered safe for the oldest old patients.

Comparison of intraoperative endoscopic retrograde cholangiopancreatography and laparoscopic common bile duct exploration combined with laparoscopic cholecystectomy for treating gallstones and common bile duct stones: a systematic review and meta-analysis

BACKGROUND

This study aimed to compare the efficacy and safety of laparoscopic cholecystectomy combined with intraoperative endoscopic retrograde cholangiopancreatography (LC-IntraERCP) and laparoscopic cholecystectomy combined with laparoscopic common bile duct exploration (LC-LCBDE) to determine which one-stage therapeutic strategy provides better outcomes for patients with gallstones and common bile duct stones.

METHODS

Cochrane Library, EMBASE, PubMed, and Web of Science databases were searched to identify eligible articles from the database inception to September 2020. The revised Cochrane risk of bias tools for randomized trials (RoB-2) and non-randomized interventions (ROBINS-I) was used to assess the quality of the included studies. The overall quality of evidence was assessed through the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool. The primary outcomes consisted of surgical success, retained stones, and overall postoperative complications, while secondary outcomes included postoperative bleeding, postoperative pancreatitis, postoperative bile leakage, conversion to laparotomy, and operative time.

RESULTS

Eight studies (four RCTs and four Non-RCTs with high quality) with 2948 patients were included. No significant difference was seen between the two groups regarding surgical success, overall postoperative complications, conversion to laparotomy, and operative time. The meta-analysis demonstrated that in the LC-IntraERCP group, the rate of retained stones (OR 0.51, 95% CI 0.28-0.91) and postoperative bile leakage were lower (OR 0.25, 95% CI 0.09-0.69), while in the LC-LCBDE group, postoperative bleeding (OR 5.24, 95% CI 1.65-16.65) and postoperative pancreatitis (OR 4.80, 95% CI 2.35-9.78) decreased.

CONCLUSIONS

LC-IntraERCP and LC-LCBDE exhibited similar efficacies when surgical success rate, overall postoperative complications, conversion to laparotomy, and operative time were compared. However, LC-IntraERCP is probably to be more effective in terms of lowering the rate of retained stones.

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

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

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Safety and efficacy of emergency laparoscopic common bile duct exploration in elderly patients with complicated acute cholangitis

BACKGROUND

Acute cholangitis (AC) is an acute inflammation of the biliary tract caused by bacterial infection, which occurs due to biliary obstruction primarily because of bile duct stones. We aimed to study the effect of laparoscopic common bile duct exploration in the treatment of complicated AC for elderly patients.

METHOD

Elderly patients with complicated AC admitted to our hospital from August 2014 to August 2018 were considered. According to the patients' general conditions and the American Society of Anesthesiologists' (ASA) grade, 98 patients were divided into three groups: ASA grade II, 38 patients; ASA grade III, 33 patients; and ASA grade IV, 27 patients; all patients underwent emergency laparoscopic common bile duct exploration within 8 h of admission. The perioperative data of these patients were analyzed.

RESULTS

There were no significant differences between the three groups in preoperative laboratory test results, except for albumin levels. Conversely, when compared in every group, there were some significant differences in changes between pre- and postoperative laboratory test results, except for albumin levels. There were no significant differences between the groups in terms of perioperative data (operation time, blood loss, peritoneal drainage time, postoperative time to flatus, and postoperative hospital stay). Although four patients had postoperative complications, there were no significant differences in the rate of complications between the groups.

CONCLUSION

Laparoscopic common bile duct exploration is a safe, effective, and feasible method for treating complicated AC in elderly patients. It should be actively used in clinical work to rapidly relieve biliary obstruction.