Open Common Bile Duct Exploration Research Articles

Management of Choledocholithiasis in a Community Hospital: Laparoscopic Common Bile Duct Exploration Versus Endoscopic Retrograde Cholangiopancreatography.

Approximately 10% of intraoperative cholangiograms identify choledocholithiasis (CDL), stones in the common bile duct. Choledocholithiasis management options include endoscopic retrograde cholangiopancreatography (ERCP) followed by cholecystectomy, laparoscopic cholecystectomy (LC) followed by ERCP (LC + ERCP), cholecystectomy with open common bile duct exploration, or laparoscopic cholecystectomy with laparoscopic common bile duct exploration (LC + LCBDE). The goal of these interventions is to clear the obstruction from CDL. Patients from a single-center community hospital undergoing LC with intraoperative cholangiogram (LC + IOC) progressing to LC + LCBDE from July 2020 to August 2022 were evaluated for hospital length of stay (LOS), operative times, and complications. These were compared to the prior standard practice of pre/post-operative ERCP. The results were evaluated using ANOVA, Student-Newman-Keuls, and chi square analysis. In comparison of LC + CBDE to ERCP + cholecystectomy, LOS was reduced (1.8 vs 4.6days P < .0001). No difference in LOS between LC + IOC and LC + CBDE (1.4 vs 1.8days, P > .05) was found. No difference in complication rates was found. Mean operative time differed between LC + IOC and LC + CBDE (63 vs 113minutes, P < .0001). Fifty-five attempts of LC + CBDE were performed with only 10 requiring post-operative ERCP. Since implementation of LC + CBDE, there has been reduced LOS without increasing complication rates. Operative times are increased with LC + CBDE but offset by reduced LOS, additional anesthesia events, and procedures. Our institution will continue to pursue LC + CBDE when indicated with efforts to improve resource allocation.

Evaluation of the ACS NSQIP surgical risk calculator in patients undergoing common bile duct exploration.

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical risk calculator is a risk stratification tool to help predict risks of postoperative complications, which is important for informed decision-making. The purpose of this study was to evaluate the accuracy of the calculator in predicting postoperative complications in patients undergoing common bile duct (CBD) exploration. A retrospective chart review was completed for 305 patients that underwent open and laparoscopic CBD exploration at a single institution from 2010 to 2018. Patient demographics and preoperative risk factors were entered into the calculator, and the predicted complication risks were compared with observed complication rates. Brier score, C-statistic, and Hosmer-Lemeshow regression analysis were used to assess discrimination and calibration. The observed rate exceeded the predicted rate for any complication (35.1% vs. 21%), return to operating room (5.9% vs. 3.6%), death (3.3% vs. 1%), and sepsis (3% vs. 2.4%). The model performed best in predicting serious complication (Brier 0.087, C-statistic 0.818, Hosmer-Lemeshow 0.695), surgical site infection (Brier 0.068, C-statistic 0.670, Hosmer-Lemeshow 0.292), discharge to rehabilitation facility (Brier 0.041, C-statistic 0.907, Hosmer-Lemeshow 0.638), and death (Brier 0.028, C-statistic 0.898, Hosmer-Lemeshow 0.004). In multivariable analysis, there was no statistically significant predicted complication type that affected the type of surgery. The calculator was accurate in predicting serious complication, surgical site infection, discharge to rehabilitation facility, and death. However, the model displayed poor predictive ability in all other complications that were analyzed.

Multicenter Study of Laparoscopic Common Bile Duct Exploration for Choledocholithiasis in the English-Speaking Caribbean.

Background Common bile duct (CBD) exploration to address choledocholithiasis is not widely practiced in the English-speaking Caribbean. This study sought to determine the frequency of laparoscopic CBD explorations in the English-speaking Caribbean and to document the stone clearance rates and short-term outcomes of this procedure. Methods We accessed records for all practicing laparoscopic surgeons in the English-speaking Caribbean who performed laparoscopic CBD explorations over a 10-year period from January 1, 2013, to June 30, 2023. The following data were extracted retrospectively from patient records: demographic details, operating time, stone clearance rates, retained stone rates, conversions, and complications. All data were analyzed with SPSS version 20 (IBM Corp., Armonk, NY). Results Over the 10-year study period, 35 patients underwent laparoscopic cholecystectomy and synchronous CBD exploration in Barbados, Cayman Islands, Guyana, Grenada, St Lucia, and Trinidad & Tobago. The procedure was performed at low volumes of only 0.7 procedures per surgical team per annum. The conversion rate to open CBD exploration was 13% and when laparoscopic CBD exploration was completed, it resulted in 96.3% stone clearance, 3.7% retained stones, mean hospitalization of two days, 9.7% minor morbidity, and no mortality. Conclusion Laparoscopic CBD exploration is feasible in the resource-poor Caribbean setting, and it yields good results, with 96.3% stone clearance rates, 9.7% minor morbidity, and no mortality. These results are better than those reported in Caribbean literature for stone extraction with endoscopic retrograde cholangiopancreaticography (ERCP).

EFFICACY AND SAFETY OF PRIMARY CLOSURE OF COMMON BILE DUCT FOLLOWING LAPAROSCOPIC CHOLEDOCHOLITHOTOMY

Following surgical intervention for symptomatic cholelithiasis, approximately 10 to 15 percent of patients are diagnosed with choledocholithiasis, characterized by the presence of stones in CBD. Several surgeons perform open CBD exploration with primary duct closure. However, few surgeons perform duct closure laparoscopically due to technical difficulties and concerns about missed stones and postoperative complications. Thus, we evaluated the efficacy and safety of the primary closure of the common bile duct following laparoscopic choledocholithotomy. In this prospective observational study, 62 patients with CBD stones were confirmed pre-operatively by abdominal ultrasonography and/or magnetic resonance cholangiopancreatography (MRCP). CBD radiological findings and demographics were noted. Details on the intraoperative technique, overall operating time, and post-operative complications were observed. Patients were followed for one month, and post-operative data were collected and analysed. Most of the enrolled patients were female (69.35%), aged 41-50 (37.10%), and had abdominal pain (82.25%). 64.52% had multiple stones in the CBD of the calibre of 8–10 millimetres (40.32%). 94.52±21.58 mins was the mean operative time. CBD clearance was noted in 96.77% of cases. In most cases, intraoperative bleeding was 51–100 ml. Laparoscopic primary closure was performed in 96.77% of patients. On days 3 and 7, 9.68% and 6.45% of patients had bile leakage, respectively. The removal of abdominal drains varied significantly between cases. During the follow-up, two patients with bile leaks and jaundice after surgery were found to have retained stones and underwent post-operative ERCP without additional complications. The primary closure after LCBDE is considered a safe and effective alternative to T-tube drainage with an acceptable short-term outcome.

Management of common bile duct stones in a tertiary care hospital

Background: Common bile duct (CBD) stone is a relatively frequent disorder in our clinical practice. Early diagnosis and prompt treatment are the most important for managing CBD stones. The various modalities of treatments in bile duct stones include open, endoscopic, and laparoscopic approaches. Aim and Objectives: CBD stones are one of the common diseases faced by both surgeons and gastroenterologists. Many patients remain asymptomatic and show mild-to-moderate dyspeptic symptoms. However, symptomatic patients are frequently associated with complications that cause a lot of suffering to the patients. At present, open, endoscopic, and laparoscopic approaches are available for the management of bile duct stones with surgical methods slowly giving a way to other two newer modalities. However, treatment modalities should be individualized. The objectives of the study are various modalities of treatments in bile duct stones and the efficacy of these modalities in terms of outcomes, morbidity, and mortality. Materials and Methods: This was a prospective study of 68 patients who were admitted to Peerless Hospital and B.K. Roy Research Center between October 2014 and December 2015. Results: In this study, CBD stones were common in females between 55 and 64 years of age group. The presentation of the disease ranged from asymptomatic to symptomatic with features of complications in the form of acute biliary pancreatitis and cholangitis. Pain was the leading symptom, followed by jaundice and fever. Transabdominal USG revealed stones in bile ducts in 41.2% of cases, and the diagnosis was suspected in 26.4% of cases by only seeing proximal dilated bile ducts. All patients underwent endoscopic retrograde cholangiopancreatography (ERCP) stone extraction procedure, and in cases where the endoscopic procedure failed, open CBD exploration was done. The success rate of open surgery is marginally high than that of endoscopic intervention. Choledochoduodenostomy was performed in one patient where the open procedure failed to extract all the stones from the bile ducts. Complications seen in ERCP are pancreatitis (4.4%), hemorrhage (2.9%), cholangitis (1.5%), and death in 1 (1.5%) patient, following a severe attack of pancreatitis. Conclusion: From the above study, it is clear that open surgery is more successful than endoscopic procedure. ERCP failed due to multiple large stones and its impaction at the lower end of CBD. Hence, the patients should be categorized properly after a pre-operative workup. Facilities for the procedure and availability of experienced doctors are also crucial in making the decision.

Multimodal treatments of “gallstone cholangiopancreatitis”

Gallstone cholangiopancreatitis is a potentially life-threatening pathology which requires quick intervention involving endoscopists, interventional radiologists, anesthesiologists and surgeons in relation to clinical conditions. Treatment possibilities are varied, especially with current progress in advanced endoscopy, interventional radiology, and minimally invasive surgery. The following treatments are available: endoscopic sphincterotomy (ES) with stone extraction followed by laparoscopic cholecystectomy; simultaneous endoscopic stone extraction with laparoscopic cholecystectomy (rendezvous technique); combined laparoscopic cholecystectomy and common bile duct (CBD) exploration; open CBD exploration; ES post-cholecystectomy; percutaneous placement of biliary drains for unstable patients, followed by percutaneous cholangioscopy; and lithotripsy with different approaches, including a laser and balloon dilation of the sphincter of Oddi. Each technique has its strengths and weaknesses, and there is great discussion in the literature on choosing the ideal approach based on the patient’s clinical conditions.

Duodenal perforation due to migrated biliary stent: Case report.

IntroductionBiliary stents are frequently associated with various complications; however biliary stent migration causing duodenal perforation is rare and has only been reported in few cases.Presentation of caseWe present a case of 33 years old male with pain abdomen and fever for 2 days came to Emergency department. He had undergone open common bile duct exploration (CBD), clearance of stone and placement of CBD stent. In X-ray abdomen, biliary stent migration was suspected. CECT abdomen was done for the confirmation of diagnosis which showed migrated stent with duodenal perforation. Patient underwent exploratory laparotomy and Thal patch repair, pyloric exclusion, retrograde duodenostomy and feeding jejunostomy. Post-operative period was uneventful.DiscussionBiliary stents are used to relieve biliary obstruction. There is increasing use of endoscopic retrograde drainage via plastic endoprosthesis and so the related morbidities. One of the rare but serious complications is intestinal perforation and duodenal perforation is seen in most of the cases, explanation being the relative fixed position of the duodenum.ConclusionAlthough intestinal perforation is an uncommon complication following CBD stenting, we should suspect it in patients presenting with pain and fever.

Comparative Study of Endoscopic Retrograde Cholangio-Pancreatography versus Surgical Open and Laparoscopic Exploration of CBD in Management of CBD Stones

Introduction and Aim: Choledocholithiasis are common presentations in daily surgical practice. Endoscopic retrograde cholangiopancreatography (ERCP) remains the gold standard management approach. However, researching new approaches is continuing due to their associated complications. The current study aimed to address the efficacy, safety, and outcomes of different treatment modalities to recognize the most appropriate technique for patients with choledocholithiasis.&#x0D; Patients and methods: The current work included 60 patients with choledocholithiasis. They were divided randomly into three equal groups. Group I for intraoperative ERCP plus LC, group II for LCBDE plus LC, and group-III for open common bile duct exploration plus cholecystectomy. Each patient was subjected to full history taking, physical examination, and different investigations (laboratory and radiological). The postoperative follow-up had been performed in the clinical and radiological follow-up.&#x0D; Results: The three groups were comparable regarding patient age, sex, body mass index, operative time, size of the common bile duct, stone number per patient, postoperative pain score, duration of hospital stay, satisfaction score. The success rate was 75%, 70% &amp; 85% of the group I, II &amp; III, respectively; while the mortality rate was 5%,10% &amp; 0% in groups I, II, and III. However, there was a statistically significant higher frequency of morbidity among Group-I than the other two groups (30% in group I compared to 5% for each of the second and third groups). Also, there was a higher rate of retained stones (25%, 30%) for groups I &amp; II with no retained stones among the third group (open surgery). There was no significant difference between groups regarding complications.&#x0D; Conclusion: The three approaches have comparable outcomes in success, mortality, morbidity, failure, and complications. The clearance and retained stone rates after primary intervention showed significant improvement in the open surgery group compared to the other groups.

“IV plasty” a novel technique: Cystic duct flap closure following common bile duct exploration in children

Choledocholithiasis is increasingly seen in children; attributable to ever increasing diagnostic ultrasound availability and to the advances in medical care, including parenteral nutrition for children who have survived neonatal short bowel syndrome. Endoscopic expertise for managing paediatric choledocholithiasis is often unavailable or the procedure unsuccessful. Many of these children have multiple comorbidities and may have had previous laparotomies. Open Common Bile Duct (CBD) exploration becomes necessary in a large percentage of such children. The size and anatomy of the biliary tree often precludes a trans -cystic approach to CBD exploration. For this reason, frequently a choledochotomy is required. To avoid CBD stricture, insertion of a T-tube or stent is recommended, but these are associated with complications and appropriate small size devices are often unavailable. We present a technique for closure of the CBD after a choledochotomy that prevents the duct from narrowing, without the use of stents. This technique can also be employed for other tubular structures. • Choledocholithiasis is increasingly seen in children. • Endoscopic management of paediatric choledocholithiasis is often unavailable/unsuccessful. • Common bile duct exploration and choledochotomy predisposes to ductal stricture. • Closure of the choledochotomy using a flap of cystic duct can prevent strictures.

Laparoscopic common bile duct exploration after failed endoscopic retrograde cholangio-pancreatography: Our patient series over a period of 10 years

Laparoscopic CBD exploration (LCBDE) for Common bile duct (CBD) stones with laparoscopic cholecystectomy (LC) is an alternative to open CBD exploration, in patients with failed endoscopic retrograde cholangio-pancreatography (ERCP). It is being performed at few centres with adequate surgical expertise. Herein, we present our experience of LCBDE with LC over a period of 10 years. A retrospective analysis of prospectively recorded data of 121 consecutive patients was performed from February 2010 to November 2019, who underwent LC and LCBDE by choledochotomy in a single surgical unit. These included all patients with failed pre-operative ERCP. Out of 121 patients, LCBDE successfully cleared the CBD in 118, and three patients were converted to open surgery. All these patients underwent choledochotomy for adequate exploration of CBD. T-tube closure of CBD was performed in 103 patients and removed after a mean of 14.6 ± 2.4 days. Primary closure was performed in 15 patients. The mean hospital stay post-procedure was 3.4 ± 0.7 days. Complete ductal clearance was achieved in 115 patients, and residual stone fragments reported in three patients were removed by ERCP. None of the patients experienced biliary peritonitis, biliary fistula, pancreatitis or cholangitis. There was no 30-day mortality and no recurrent stones reported with a mean follow-up of 12.4 ± 3.9 months. With adequate surgical expertise, LCBDE is a feasible alternative to open surgery for CBD stones after failed ERCP with early recovery and low morbidity.

EP.WE.46Stentolith as an uncommon complication of loss to follow up after endoscopic biliary stenting

Abstract Introduction Endoscopic biliary stenting is a common procedure, with indications from malignant obstruction to benign stone disease. We discuss a patient who re-presented after endoscopic stenting having been lost to follow up, with a large ‘stentolith’ requiring open CBD exploration. Case Presentation A 56-year-old female presented in 2013 with obstructive jaundice and a 2-week history of abdominal pain. She was a smoker, but otherwise had no past medical, surgical, or relevant family history. After initial workup, ERCP with sphincterotomy and pigtail stent placement was performed with interval laparoscopic cholecystectomy in 2014. Post-operative follow up was not arranged, the patient subsequently re-presented in 2020 with fatigue. MRCP confirmed a proximal CBD stone and linear artefact. Open exploration facilitated removal of the stone-stent complex. Discussion Complications of stenting include cholangitis, stent occlusion and migration. Stenting for failed biliary stone extraction is considered a temporary measure, with removal or exchange at three months. However, patients may be lost to follow up and return with non-specific symptoms. A rare cause is de novo formation of a gallstone calculus encasing the stent, a phenomenon termed “stentolith”. Proposed pathophysiology is through promotion of bacterial proliferation by the stent, with biofilm formation and calcium bilirubinate precipitation. Variation in formation has been described, with plastic stents developing circumferential stones, due to potential space between the wall and stent. Conclusion This highlights the importance of robust inter-disciplinary working, careful patient follow up and implementation of a mandatory registry at all hospitals for stented patients.

106 Stentolith As an Uncommon Complication of Loss to Follow Up After Endoscopic Biliary Stenting

Abstract Introduction Endoscopic biliary stenting is a common procedure, with indications from malignant obstruction to benign stone disease. We discuss a patient who re-presented after endoscopic stenting having been lost to follow up, with a large ‘stentolith’ requiring open CBD exploration. Case Presentation A 56-year-old female presented in 2013 with obstructive jaundice and a 2-week history of abdominal pain. She was a smoker, but otherwise had no past medical, surgical, or relevant family history. After initial workup, ERCP with sphincterotomy and pigtail stent placement was performed with interval laparoscopic cholecystectomy in 2014. Post-operative follow up was not arranged, and the patient subsequently re-presented in 2020 with fatigue. MRCP confirmed a proximal CBD stone and linear artefact. Open exploration facilitated removal of the stone-stent complex. Discussion Complications of stenting include cholangitis, stent occlusion and migration [2]. Stenting for failed biliary stone extraction is considered a temporary measure, with removal or exchange at three months (1). However, patients may be lost to follow up and return with non-specific symptoms. A rare cause is de novo formation of a gallstone calculus encasing the stent, a phenomenon termed “stentolith” [4]. Proposed pathophysiology is through promotion of bacterial proliferation by the stent, with biofilm formation and calcium bilirubinate precipitation [6]. Variation in formation has been described, with plastic stents developing circumferential stones [12-25], due to potential space between the wall and stent. Conclusions This highlights the importance of robust inter-disciplinary working; careful patient follows up and implementation of a mandatory registry at all hospitals for stented patients.

Primary Closure after Open Common Bile Duct Exploration in Comparison to T-tube Drainage. Our Experience in a New Medical College of Assam

Background: Traditionally T-tube drainage of CBD is most commonly done. However T-tube has its ownproblems mainly longer hospitalisation, longer absence from work and many complications. This study doneto assess outcome of primary closure of CBD after open CBD exploration.Methods: This retrospective study was done in Tezpur Medical College which is a new medical college inAssam. All the patients who underwent CBD exploration in our unit were analysed to compare the results.All together 38 patients underwent CBD exploration of which in 18 primary closure of CBD was done.Results and Conclusion: Our results indicate lesser complications for primary closure, much shorterhospital stay in comparison to T-tube drainage.Primary closure of CBD after choledocholithotomy is safe, much simple and effective and has lessercomplications in comparison to T-tube drainage.

Outcomes of same admission cholecystectomy and endoscopic retrograde cholangiopancreatography for common bile duct stones: A post hoc analysis of an Eastern Association for the Surgery of Trauma multicenter study.

The optimal timing for cholecystectomy after endoscopic retrograde cholangiopancreatography (ERCP) for common bile duct (CBD) stones is unknown. We hypothesized that a delay between procedures would correlate with more biliary complications and longer hospitalizations. We prospectively identified patients who underwent same admission cholecystectomy after ERCP for CBD stones from 2016 to 2019 at 12 US medical centers. The cohort was stratified by time between ERCP and cholecystectomy: ≤24 hours (immediate), >24 to ≤72 hours (early), and >72 hours (late). Primary outcomes included operative duration, postoperative length of stay, (LOS), and hospital LOS. Secondary outcomes included rates of open conversion, CBD explorations, biliary complications, and in-hospital complications. For the 349 patients comprising the study cohort, 33.8% (n = 118) were categorized as immediate, 50.4% (n = 176) as early, and 15.8% (n = 55) as late. Rates of CBD explorations were lower in the immediate group compared with the late group (0.9% vs. 9.1%, p = 0.01). Rates of open conversion were lower in the immediate group compared with the early group (0.9% vs. 10.8%, p < 0.01) and in the immediate group compared with the late group (0.9% vs. 10.9%, p < 0.001). On a mixed-model regression analysis, an immediate cholecystectomy was associated with a significant reduction in postoperative LOS (β = 0.79; 95% confidence interval, 0.65-0.96; p = 0.02) and hospital LOS (β = 0.68; 95% confidence interval, 0.62-0.75; p < 0.0001). An immediate cholecystectomy following ERCP correlates with a shorter postoperative LOS and hospital LOS. Rates of CBD explorations and conversion to open appear more common after 24 hours. Therapeutic, level III.

T-tube in Moderation: T-tube Drainage versus Primary Closure after Open Common Bile Duct Exploration for Common Bile Duct Stone: A Single Institution Experience

Introduction: To discuss and compare outcomes and complications of routine T-Tube placement versus primary closure in patients who underwent open common bile duct exploration for choledocholithiasis. Methods: This is a randomized prospective analysis of 35 patients categorized as moderate to high risk for CBD stone who underwent open choledochotomy. Thirty (30) patients were included and were randomly divided into 2 groups: T-tube drainage (TD, n=20) and primary closure (PC, n=10). Morbidity was graded using the Clavien-Dindo (CD) classification. Results: Patients in the TD group had less overall complications than patients in the PC group (20% vs 30%, respectively; p=0.083); however, the TD group had more severe (CD Grade III or higher) complications than the PC group (75% vs 0% respectively; p=0.052). Complications included two patients with bile leak for pulled t-tube, post-op biliary stricture and acute kidney injury which required dialysis. Most of the complications in the PC group (3/10, or 30%) were minor complications (CD 1 or 2). There was no mortality in both groups. All 30 patients were followed-up for 3-12 months, with a median follow-up time of 6 months. Conclusion: There was no statistically significant difference between T-tube placement and primary closure in terms of morbidity and long-term outcomes. Primary closure of the choledochotomy after biliary exploration for common bile duct stones is a safe and feasible alternative to routine T-tube drainage in carefully selected cases.

Primary Closure after Laparoscopic CBD Exploration- Experience of More than 400 Cases over 12 Years at a Tertiary Care Center

Introduction: T tube placement after common bile duct (CBD) exploration has been the standard since the era of open CBD exploration. We hereby report our experience and long term outcomes of over 400 cases of laparoscopic CBD exploration where in primary closure of CBD was done without T -Tube placement. Methods: All patients with CBD stones undergoing laparoscopic common bile duct exploration (LCBDE) in a single surgical unit at a tertiary care center were studied from April 2007 to October 2019. MRCP served as a road map and patients were taken up for LCBDE if the CBD diameter was more than 10 mm. Intraoperative details including the mode of closure of bile duct (primary, T Tube or endobilliary stent) were noted. The post-operative recovery, complications, hospital stay, antibiotic usage and post-operative intervention if any were also recorded. Results: 414 patients underwent LCBDE during this period. The mean age was 50 ± 15.2 years and majority were females (68.8%). 180 (43.47%) patients had failed ERCP. CBD was closed primarily in 97.58% (n=404) cases. Endobiliary stent was placed in 90 (21.73%) patients and only primary closure in 314 cases. T tube was used in 5 cases with a total of 34 conversion to open CBD exploration. Successful laparoscopic CBD clearance was achieved in 380 patients (success rate 91.80%). Conclusion: Primary closure of CBD following laparoscopic CBD exploration is safe and associated with minimal complications. The routine use of primary CBD closure after laparoscopic CBD exploration is recommended based on our experience.

Laparoscopic common bile duct exploration for patients with a history of prior biliary surgery: a comparative study with an open approach.

Laparoscopic common bile duct exploration (LCBDE) is increasingly being used to treat choledocholithiasis. However, few studies have examined the treatment of recurrent common bile duct stones (CBDS) in patients with a history of prior biliary surgery. The current research aimed to compare the outcomes of laparoscopic versus open common bile duct exploration in patients with a history of prior biliary surgery. Between March 2010 and August 2019, 162 patients with recurrent CBDS after prior biliary surgery who underwent surgical management in our institution were enrolled in this study. The demographic, intraoperative and postoperative data were retrospectively analysed. Among these 162 patients, 72 underwent laparoscopic approach (LCBDE group), and 90 underwent open surgery (open common bile duct exploration group). The LCBDE group was associated with significantly lower overall complication rate, incision infection rate and blood loss compared to open common bile duct exploration group (all P < 0.05). Moreover, the laparoscopic approach significantly reduced the length of postoperative hospital stay (P < 0.05). However, the operative time, stone clearance rate, and stone recurrence rate were not significantly different between the two groups (P > 0.05). The conversion rate of the laparoscopic approach was 6.9%. LCBDE is superior to open procedure in terms of blood loss, hospital stay, overall complication and incision infection in patients with a history of prior biliary surgery, and it should be considered as a safe and effective treatment if it is performed by an experienced surgeon.

English

English

Innovative hybrid technique of bile duct exploration in the treatment of Choledocolithiasis

Common bile stone disease (CBDS) is frequent and has potentially severe complications, such as acute biliary pancreatitis and cholangitis. Unnecessary and unplanned procedures must be avoided, so before choosing the best treatment of common bile duct lithiasis it is essential to have a proper diagnose. CBDS is currently treated by therapeutic endoscopic retrograde cholangiopancreatography (ERCP) or laparoscopic bile duct exploration (LCBDE). The aim of this article is to present a innovative hybrid technique of common bile duct exploration, on account of one option in those cases where the laparoscopic approach is not resolutive, avoiding the need of conversion to open approach technique. The hybrid technique has the same benefits of open and laparoscopic techniques, but without increasing costs with material and with good resolutivity in complex cases of common bile duct stones. Keywords: Choledocholithiasis; laparoscopic common bile duct exploration; LCBDE; open common bile duct exploration

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

BackgroundA history of abdominal biliary tract surgery has been identified as a relative contraindication for laparoscopic common bile duct exploration (LCBDE), and there are very few reports about laparoscopic procedures in patients with a history of abdominal biliary tract surgery.MethodsWe retrospectively reviewed the clinical outcomes of 227 consecutive patients with previous abdominal biliary tract operations at our institution between December 2013 and June 2019. A total of 110 consecutive patients underwent LCBDE, and 117 consecutive patients underwent open common bile duct exploration (OCBDE). Patient demographics and perioperative variables were compared between the two groups.ResultsThe LCBDE group performed significantly better than the OCBDE group with respect to estimated blood loss [30 (5–700) vs. 50 (10–1800) ml; p = 0.041], remnant common bile duct (CBD) stones (17 vs. 28%; p = 0.050), postoperative hospital stay [7 (3–78) vs. 8.5 (4.5–74) days; p = 0.041], and time to oral intake [2.5 (1–7) vs. 3 (2–24) days; p = 0.015]. There were no significant differences in the operation time [170 (60–480) vs. 180 (41–330) minutes; p = 0.067]. A total of 19 patients (17%) in the LCBDE group were converted to open surgery. According to Clavien’s classification of complications, the LCBDE group had significantly fewer postoperative complications than the OCBDE group (40 vs. 57; p = 0.045). There was no mortality in either group. Multiple previous operations (≥ 2 times), a history of open surgery, and previous biliary tract surgery (including bile duct or gallbladder + bile duct other than cholecystectomy alone) were risk factors for postoperative adhesion (p = 0.000, p = 0.000, and p = 0.000, respectively).ConclusionLCBDE is ultimately the least invasive, safest, and the most effective treatment option for patients with previous abdominal biliary tract operations and is especially suitable for those with a history of cholecystectomy, few previous operations (< 2 times), or a history of laparoscopic surgery.