Open Common Bile Duct Exploration Research Articles

Retrospective Clinical Study of the Effects of T-Tube Placement for Bile Duct Stricture.

BackgroundT-tube placement in the common bile duct (CBD) is a surgical alternative to bile duct reconstruction in cholecystectomy for cholecysto-choledocholithiasis, or gallstones. The aim of this retrospective clinical study was to investigate the incidence of late complications of T-tube placement.Material/MethodsRetrospective review identified 35 patients who had T-tube placement during cholecystectomy. Clinical data were collected on surgical indications, patient demographics, and clinical symptoms. Ultrasound (US) was used measure the diameter of the common bile duct (CBD), intrahepatic ducts, and presence or absence of stones in the CBD. Data from laboratory investigations included the aspartate aminotransferase-to-platelet ratio index (APRI), which was used as a non-invasive method to evaluate both cholestasis and liver fibrosis.ResultsOf the 35 patients included in the study, 33 (94.3%) underwent open cholecystectomy, CBD exploration, and T-tube placement due to cholecysto-choledocholithiasis. The remaining two patients (5.7%) underwent primary CBD repair and T-tube placement secondary to CBD injury. The mean follow-up period after T-tube placement was 69 months. In patients with T-tube placement, the CBD diameters ranged from 4–21 mm, were normal in 20 patients (57.1%), dilated in 15 patients (42.9%), with the mean CBD diameter being 8.91±4.82 mm. No residual or recurrent CBD calculus and no clinical or laboratory evidence of cholangitis or cholestasis were found.ConclusionsA retrospective clinical study at a single surgical center, showed that T-tube placement during open cholecystectomy and CBD exploration was a safe procedure that did not result in late complications.

Advantages of laparoscopic common bile duct exploration in common bile duct stones.

To compare the efficacy, safety, and surgical outcomes of laparoscopic common bile duct exploration, endoscopic retrograde cholangiopancreatography, and open common bile duct exploration for treatment of common bile duct stones. In total, 210 patients were prospectively randomized into 3groups: laparoscopic common bile duct exploration, endoscopic retrograde cholangiopancreatography, and open common bile duct exploration. The primary outcome measures were the common bile duct stone clearance rate and the complication rate. The secondary outcome measures were mortality, total costs, and length of hospital stay. The success rates in the laparoscopic common bile duct exploration group (97.14%, 68 out of 70) and open common bile duct exploration group (98.57%, 69/70) were significantly higher than that in the endoscopic retrograde cholangiopancreatography group (85.71%, 60/70, both p< 0.05). The complication rates in the laparoscopic common bile duct exploration group (2.86%, 2/70) and open common bile duct exploration group (1.43%, 1/70) were significantly lower than that in the endoscopic retrograde cholangiopancreatography group (14.29%, 10/70, both p< 0.05). The success rate and complication rate were not significantly different between the laparoscopic common bile duct exploration group and open common bile duct exploration group (both p> 0.05). Laparoscopic common bile duct exploration provides an alternative therapeutic approach that was safer and more reliable, allowed for earlier recovery, and provided more cost-effective treatment of common bile duct stones.

Resident Operative Experience at Independent Academic Medical Centers—A Comparison to the National Cohort

Independent Academic Medical Centers (IAMCs) comprise one-third of U.S. general surgery training programs. It is unclear whether IAMCs offer qualitatively or quantitatively different operative experiences than the national cohort. We analyzed a large representative sample of IAMCs to compare operative volume and variety, with a focus on low-volume procedures. Accreditation Council for Graduate Medical Education Program Case Reports from 27 IAMCs were collected and analyzed for 3 academic years (2012-2015). IAMCs were compared to the national cohort for specific defined category volumes and selected low-volume cases. One-sample two-way t-tests were calculated comparing IAMC totals to national program averages. IAMCs had a median of 3 chief residents per year (range: 1-6). IAMCs reported significantly more "total major" procedures in 2013-2014 (p = 0.046). Other case totals were statistically similar between IAMCs and the national cohort for "total major", "surgeon chief", "surgeon junior", and "teaching assistant" cases. In 2013-2014, IAMCs reported more laparoscopic complex (138.3 vs. 110.6, p = 0.010) and alimentary tract cases (276.5 vs. 253.5, p = 0.019). IAMC esophagogastroduodenoscopy case totals were higher in 2013-2014 (55.9 vs. 41, p = 0.038) and 2014-2015 (47.8 vs. 41, p = 0.047). IAMCs had fewer pancreas cases than the national cohort in all three years by about three cases per resident (p ≤ 0.026). In 2012-2013 IAMCs reported fewer (by about one) esophagectomy, gastrectomy, and abdominal perineal resections. No differences were observed in the following selected procedures: open common bile duct exploration, inguinal hernia, laparoscopic appendectomy, laparoscopic cholecystectomy, and colonoscopy. The IAMCs studied appear to provide equivalent exposure to specific subcategories mandated by the Accreditation Council for Graduate Medical Education and American Board of Surgery. Graduates of IAMCs gain similar operative experience in low-volume, defined categories when compared to the national cohort. Certain specific cases subject to regionalization pressure are less well represented among IAMCs. This has important implications for medical students applying to surgery residency.

Laparoscopic surgery for choledocholithiasis concomitant with calculus of the left intrahepatic duct or abdominal adhesions.

Laparoscopic common bile duct exploration (LCBDE) has been widely promoted in recent years as a safe and effective treatment for choledocholithiasis. However, there are no standard guidelines for the treatment of patients who have concomitant hepatolithiasis of the left liver and abdominal adhesions. The aim of the current research was to compare the outcomes of open versus laparoscopic common bile duct exploration with left hepatectomy (OCBDH vs. LCBDH) in patients with choledocholithiasis concomitant with left-sided hepatolithiasis, and to evaluate the safety and feasibility of laparoscopic surgery for choledocholithiasis in patients with abdominal adhesions. Between October 2012 and October 2015, a total of 321 consecutive patients with choledocholithiasis underwent surgical treatment. LCBDE was performed in 107 patients, and open common bile duct exploration (OCBDE) was performed in 111 patients. Further, 31 patients and 72 patients underwent LCBDH and OCBDH, respectively. A total of 133 patients who underwent LCBDE or OCBDE had abdominal adhesions, which were classified as mild, moderate, or severe according to an abdominal adhesion scoring system, which was validated in the LCBDE group and OCBDE group. The perioperative results were reviewed and analyzed retrospectively. In the mild adhesion group, blood loss, postoperative recovery in the LCBDE group was lesser than those in the OCBDE group. In the moderate adhesion group, the postoperative recovery was significantly shorter in the LCBDE group than in the OCBDE group. In the severe adhesion group, the operation time and blood loss in the LCBDE group were higher than those in the OCBDE group. The postoperative recovery was significantly better in the LCBDH group than in the OCBDH group. LCBDH can obviously improve recovery and shorten the hospitalization period. Further, LCBDE is safe and feasible for patients of choledocholithiasis with mild and moderate abdominal adhesions.

Open Surgery versus Endoscopic Intervention in the Management of Bile Duct Stones

Background: Choledocholithiasis or the presence of common bile duct stones (CBDS) is one of the medical conditions that requires surgical intervention. The management of choledocholithiasis has evolved from open common bile duct exploration (OCBDE) to therapeutic endoscopic retrograde cholangiopancreatography (ERCP) to laparoscopic common bile duct exploration (LCBDE). Each entails a degree of difficulty. In this review we aim toassess and compare the benefits and pitfalls of open surgery (OCBDE) versus endoscopic retrograde cholangiopancreatography (ERCP) in management of common bile duct stones. Methods: A systematic review of the electronically searched publications of the scientific literature. We searched the Cochrane HepatoBiliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE (1946 to 2016), EMBASE (1974 to 2016), and Science Citation Index Expanded (1900 to 2016). Initially all randomized clinical trials which compared the results from open surgery versus endoscopic clearance for common bile duct stones were included, articles were selectively screened according to the eligibility criteria. Results: eight publications were selectively included with 761 participants compared to open surgical clearance with ERCP. All trials had a high risk of bias. There was no significant difference in the mortality between open surgery versus ERCP clearance (eight trials; 733 participants; 5/371 (1%) versus 10/358 (3%) OR 0.51;95% CI 0.18 to 1.44). Neither was there a significant difference in the morbidity between open surgery versus ERCP clearance (eight trials; 733 participants; 76/371 (20%) versus 67/358 (19%) OR 1.12; 95% CI 0.77 to 1.62). Participants in the open surgery group had significantly fewer retained stones compared with the ERCP group (seven trials; 609 participants; 20/313 (6%) versus 47/296 (16%) OR 0.36; 95% CI 0.21 to 0.62), P = 0.0002. Meta-analysis of the outcomes duration of hospital stay, quality of life, and cost of the procedures could not be performed due to lack of data. Conclusion: open surgery intervention in order to remove the gallbladder and trapped gallstones appears to be as safe as endoscopy and further suggested to be more successful than the endoscopic technique in clearing the duct stones.

Preliminary outcomes of laparoscopic versus open common bile duct exploration: the mater experience

Objective: ERCP is the gold standard treatment for stones in the common bile duct (CBD). Open or laparoscopic exploration of the CBD is only warranted where ERCP is unsuccessful, or if the patient's anatomy is unamenable to ERCP such as in cases of prior gastrectomy. We report the outcomes of open and preliminary outcomes of laparoscopic approaches. Methods: An audit of outcomes of CBD exploration for gallstones from 1 Jan 2008 to July 2016 was performed. Demographic and clinical data of patients in the study group is included below. Mater Morbidity and Mortality Audit data was used to identify complications, which were then graded using the Clavien–Dindo classification. Results: A total of 30 patients underwent CBD exploration: 20 open and 10 via laparoscopic approach. The mean age at surgery was 67 in the open group, 61 in laparoscopic group, (range: 30–80). In the open CBD cohort, 10% (2/20) were performed due to complication of ERCP compared to 0% in the laparoscopic cohort. The duct was cleared in 90% (18/20) of cases in those who underwent open procedure compared to 70% duct clearance (7/10) of those who underwent laparoscopic approach. The 30-day mortality in the open cohort was 5% (1/20) compared to 0% in patients explored laparoscopically. Conclusion: Laparoscopic CBD exploration is a new treatment modality available for CBD stones. Preliminary results suggest that both open and laparoscopic approaches are safe and effective in cases of unsuccessful ERCP.

Is it time to write obituary for open choledocholithotomy in the present era of endoscopic management? Outcome of surgery for failed endoscopic extraction, retrospective study

Background: Between 05 to 20 percent of patients undergoing cholecystectomy for gallstones, have choledocholithiasis. Treatment of the common bile duct (CBD) stones can be conducted as open cholecystectomy and open CBD exploration or laparoscopic cholecystectomy plus laparoscopic CBD exploration (LC + LCBDE) versus pre- or post-cholecystectomy endoscopic retrograde cholangiopancreatography (ERCP) in two stages, usually combined with either sphincterotomy or sphincteroplasty (papillary dilatation) for CBD clearance. The merits and demerits of individual techniques are yet to be settled.Methods: We reviewed the outcome of patients operated at our centre after failed endoscopic clearance of CBD stones. Over a period of 03 years, total 2145 laparoscopic/open cholecystectomies were performed at our institute. In the same time period, 14 patients (06 males and 08 females) presented with choledocholithiasis after failed ERCP extraction (median age 59 years, range 29-62 years). All the patients had undergone ERCP and ± sphincterotomy/sphincteroplasty with failed clearance. None of the patient had undergone a cholecystectomy previously.Results: We performed open choledocholithotomy with T-tube drainage plus cholecystectomy in all the patients. There were no deaths and only one major complication. Surgery resulted in complete duct clearance in 93% of patients.Conclusions: Open surgery can be performed safely and effectively in patients with retained bile duct stones and surgery can be offered as primary modality of treatment over combined endoscopic management after appropriated patient selection.

Outcomes of Laparoscopic vs Open Common Bile Duct Exploration: Analysis of the NSQIP Database

Common bile duct exploration (CBDE) is an available option in the management of choledocholithiasis. We aimed to analyze outcomes comparing laparoscopic and open approaches to CBDE using the American College of Surgeons (ACS) NSQIP database. This was a retrospective cohort study of patients undergoing CBDE between 2008 and 2013, using the ACS NSQIP database. The cohort was split into 2 groups and compared based on operative approach: laparoscopic vs open CBDE. There were 2,635 patients who underwent CBDE during the study period, and 52% underwent an open approach. After adjusting for all confounding variables, open CBDE was associated with a statistically significant increase in mortality (adjusted odds ratio [AOR] 2.95; 95% CI 1.18 to 7.41; p= 0.02), composite morbidity (AOR 2.19; 95% CI 1.56 to 3.07; p < 0.0001), bleeding (AOR 1.86; 95% CI 1.11 to 3.12; p= 0.02), return to the operation room (AOR 1.90; 95% CI 1.16 to 3.12; p= 0.01), and readmission related to the first operation (AOR 1.55; 95% CI 1.00 to 2.39; p= 0.05). On the other hand, retained common bile duct stones were 2.8 times more likely to occur in the laparoscopic group. The mean operative time was longer by 73 minutes for patients who underwent open CBDE. Patients undergoing open CBDE suffer from a statistically significantly higher rate of mortality and overall complications compared with patients undergoing the laparoscopic approach. Laparoscopic CBDE should be considered as the preferred procedure whenever possible.

胆总管探查改良自行脱落胆管支架引流与T管引流的比较

目的：探讨胆总管探查T管引流的替代方法。方法：胆总管结石患者采用开腹手术，进行胆总管切开探查取石后，通过导丝将蝴蝶结形可自行脱落支架管的远端置入十二指肠，胆总管切口一期缝合。结果：该法治疗31例患者，选择同期完成的放置T管引流30例患者作为对照组；术后平均住院时间分别为9.1 d和14.9 d (P < 0.05)，两组近期并发症及肝功能水平无明显差异。全部支架管自行脱落并随粪便排出，支架排出时间为(13.8 ± 2.91) d。结论：胆总管探查术中在胆总管下端放置蝴蝶结形可自行脱落支架管是T管引流的有效替代方法，可减少T管引流的相关并发症。 Objective: To explore the alternative methods of T-tube drainage in common bile duct exploration. Methods: Open common bile duct exploration (OCBDE) was done in patients with common bile duct (CBD) stones. After extraction of stones, the bowknot-liked stent was pushed into the distal part of the bile duct and lumen of the duodenum over a guide wire. The CBD incision was primarily closed. Results: This technique was used in 31 patients. While T-tube placement was performed in 30 patients of control group. The average postoperative hospital stay was 5.7 and 9.5 days (P < 0.05). There was no difference between the two groups on both the early postoperative complications and liver function. All the stents had been discharged with stool. The average time of the stent discharge was (13.8 ± 2.91) postoperative days. Conclusion: During OCBDE, it was an efficient alternative method to place the bowknot-liked stent at the lower end of common bile duct. It can reduce the complications related to T-tubes.

Common bile duct clearance of stones by open surgery, laparoscopic surgery, and endoscopic approaches (comparative study)

Background and aim of the work Around 10–18% of patients undergoing cholecystectomy for gallstones have common bile duct (CBD) stones. Treatment can be provided as open cholecystectomy plus open CBD exploration, laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC+LCBDE), or precholecystectomy or postcholecystectomy endoscopic retrograde cholangio-pancreatography (ERCP) in two stages for CBD clearance. The aim of this study is to compare the CBD clearance rate by each procedure in a well-equipped tertiary center. Patients and methods A total of 250 patients with choledocholithiasis were included from the General Surgery Department, Sohag and Assiut University Hospitals, and managed randomly by either conventional surgery, endoscopic, or laparoscopic procedures. Results The ages of our patients ranged from 20 to 60 years (mean=40 years), with a slight female predominance (1.6 : 1); most of them presented with calcular obstruction (54.3%). However, there were also other presentations such as colic, cholangitis, or accidental discovery in 14.3, 10, and 21.5%, respectively. Patients were categorized randomly into three groups: group I included 100 patients (40%) who were treated by open choledocholithotomy and T-tube insertion; the operative time was 90 (60–180) min, with the success rate of the attempted procedures reaching 100%, and CBD clearance of stones was achieved in 95% of cases (five cases of missed stones). Hospital stay was 8 (5–12) days, with no mortality, and morbidity rate reached 15% in the form of wound infection, bile leak, and missed stone. The patient could return to work after 2 weeks (12–20 days). Group II included 100 patients (40%) treated by endoscopic sphincterotomy; basket extraction was performed in 45%, balloon in 25%, the combined maneuver in 15%, and mechanical lithotripsy in 13%, with failure of the technique in two cases (2%); the duration of the procedure was about 30 (20–45) min, with a success rate of attempted procedures of 98%, and CBD clearance of stones was achieved by 100%, with no mortality; the morbidity rate was 9% in the form of cholangitis (3%) and mild pancreatitis with hyperamylasemia (6%). The period of hospital stay was 1 (1–2) days and the patient returned to work after 3 (2–5) days. Group III included 50 patients (20%) treated by laparoscopic approaches: transcystic approaches in five cases and transcholedochotomy approaches in 45 cases. Choledochoscopic exploration was performed in almost all cases (45 cases) to detect, extract the stones, and test CBD clearance, and there was conversion to open techniques in one case. The time needed for this procedure was 123 (70–292) min, with CBD clearance of stones in 96% (two cases of missed stone), with no mortality, and a morbidity rate of about 10% in the form of mild hyperamylasemia, fever, and missed stone. The period of hospital stay was 3.2 (2–4) days, with return to work after 7 (5–10) days. Conclusion Both ERCP/LC and LCBDE were highly effective in CBD clearance, and equal in terms of the overall cost and patient acceptance. However, the overall duration of hospitalization was shorter for LCBDE with elimination of the potential risks of ERCP-associated pancreatitis, further procedures, and anesthesia risks. It is feasible, cost-effective, and ultimately should be available for most patients in each specialized center.

腹腔镜胆总管探查一期缝合术2326例报告

目的：总结运用腹腔镜胆总管探查一期缝合术的治疗经验。方法：回顾性分析1992年6月至2017年6月，成都市第二人民医院运用腹腔镜胆总管探查一期缝合术对2326例病人进行治疗的经验及效果。结果：一期缝合的2326例病人中有2148例(92.3%)腹腔镜手术获成功，中转开腹获成功15例(0.6%)。术后胆汁漏94例(4.0%)，术后残石29例(1.2%)，1例胰腺癌术后15 d死亡(0.1%)，术后有其他并发症39例(1.7%)，总并发症发生率为7.0% (163/2326)。结论：从本研究对本医院有限病例进行初步研究发现，只要选择合适的病例，腹腔镜胆总管探查一期缝合术是可行、有效和安全的。 Objective: To summarize the experience on laparoscopic choledochotomy with primary suture. Methods: From June 1992 to June 2017 in the Second People,s Hospital of Chengdu, 2326 patients were received the primary closure of duct incision in laparoscopic common bile duct exploration. Results: It had obtained successful in 2148 (92.3%) out of 2326 patients, fifteen cases (0.6%) were shifted to open common bile duct exploration. Bile leakage occurred in 94 cases (4.0%). Residual stones were in 29 cases (1.2%). One patient (0.1%) of pancreatic carcinoma died in post-operation 15 days. Thirty-nine cases (1.7%) were other complications. Total postoperative complication formation rate is 7.0% (163/2326). Conclusion: From preliminary results of limited cases in this study in our hospital, if patients are suitable, laparoscopic choledochotomy with primary closure was a feasible, safe and effective method.

T-Tube Versus Biliary Stent as Decompression Procedure after Open Common Bile Duct Exploration in Patients of Choledocholithiasis

T-Tube Versus Biliary Stent as Decompression Procedure after Open Common Bile Duct Exploration in Patients of Choledocholithiasis

Nationwide Assessment of Trends in Choledocholithiasis Management in the United States From 1998 to 2013

There are currently 2 widely accepted treatment strategies for patients presenting to the hospital with choledocholithiasis. However, the rate of use for each strategy in the United States has not been evaluated, and their trends over time have not been described. Furthermore, an optimal management strategy for choledocholithiasis has yet to be defined. To evaluate secular trends in the management of choledocholithiasis in the United States and to compare hospital length of stay between patients with choledocholithiasis treated with endoscopic retrograde cholangiopancreatography with laparoscopic cholecystectomy (ERCP+LC) vs laparoscopic common bile duct exploration with laparoscopic cholecystectomy (LCBDE+LC). In this cohort study, we studied patients with a primary diagnosis of choledocholithiasis that were included in the National Inpatient Sample between 1998 and 2013 from a representative sample of acute care hospitals in the United States. Patients with cholangitis or pancreatitis were excluded. Unadjusted and risk-adjusted median hospital length of stay. Of the 37 207 patients included in our analysis, 36 048 (96.9%) were treated with ERCP+LC and 1159 (3.1%) were treated with LCBDE+LC. The mean (SD) age of patients treated with ERCP+LC was 50.7 (21.1) years and was 51.9 (20.9) years for those treated with LCBDE+LC; 25 788 (69.3%) were female. Analysis of the National Inpatient Sample data indicates that there are an average of 26 158 patients with choledocholithiasis admitted in the United States each year. The overall use of CBDE for patients with choledocholithiasis decreased from 39.8% of admissions in 1998 to 8.5% in 2013 (P < .001). A decrease was also seen for open CBDE (30.6% vs 5.5%; P < .001) and laparoscopic CBDE (9.2% vs 3.0%; P < .001) independently. Rates of management with LCBDE+LC decreased from 5.3% to 1.5% (P < .001), while rates of ERCP+LC increased from 52.8% to 85.7% (P < .001). The unadjusted median hospital length of stay was shorter for patients treated with LCBDE+LC than for those treated with ERCP+LC (3.0 vs 4.0 days; P < .001). After risk-adjustment, the median length of stay remained 0.5 days shorter for patients treated with LCBDE+LC than with ERCP+LC (3.5 vs 4.0 days; P < .001). This study highlights the marked decline in the use of both open and laparoscopic CBDE in the United States as well as the benefit to the length of stay LCBDE+LC has over ERCP+LC. Despite a persistent need for CBDE and the potential benefits of LCBDE+LC over ERCP+LC for managing choledocholithiasis, if current trends continue, CBDE may be at risk of disappearing from the surgical armamentarium.

Utilization of the flexible adult bronchoscope for performing intraoperative choledochoscopy during open common bile duct exploration for choledocholithiasis: a cost effective utilization of resources

Intraoperative evaluation of the common bile duct is required for assessment of completeness of stone clearance following common bile duct exploration for management of choledocholithiasis. This is usually done by performing an Intraoperative cholangiography. However, intraoperative cholangiography can miss radio-lucent stones, and can be confusing if air is present in the biliary system. Intraoperative choledochoscopy allows direct visualization and confirmation of completeness of stone clearance. It also permits instrumentation to clear retained stones and to directly obtain mucosal biopsies. However, in most hospitals the flexible choledochoscope is not easily available because of its limited scope of utilization, but the flexible bronchoscope due to its wider use by various departments and specialties, is usually available. Since 2003, we have used the flexible adult video Bronchoscope to perform choledochoscopy in 49 patients undergoing open common bile duct exploration. In 18 patients, retained stones were removed by using the bronchoscope grasping forceps. Mucosal biopsies were performed in 7 patients. We now routinely perform choledochoscopy in all patients undergoing common bile duct exploration by using the bronchoscope. Along with the data, a short video clip is also being presented.

Multiple Preoperative Endoscopic Retrograde Cholangiopancreatography and Large Common Bile Duct Diameter Predict the Need for Complex Surgery

Endoscopic retrograde cholangiopancreatography (ERCP) is frequently used to clear the common bile duct (CBD) in patients with choledocholithiasis. While a single ERCP is usually effective, many patients undergo multiple ERCP attempts before cholecystectomy. Here we sought to identify preoperative factors predictive of surgical complexity beyond routine laparoscopic cholecystectomy after ERCP. Data were prospectively collected for all ERCPs between September 2010 and February 2012 at a public academic medical center including demographics, indication, stone presence, CBD diameter, sphincterotomy, stent placement, and ERCP number. A total of 124 ERCPs were attempted in 73 patients with choledocholithiasis, 10 per cent of whom presented with cholangitis. Fifty-six per cent of patients underwent one ERCP, whereas 16 per cent required ≥ 3 procedures. Laparoscopic cholecystectomy was performed in 58 (79%) patients whereas 15 (21%) patients required more complex operations including eight open CBD explorations and two hepaticojejunostomies. The likelihood of requiring more complex surgery correlated with increasing number of ERCPs with an adjusted odds ratio of 5.75 (95% confidence interval: 2.31-14.3, P ≤ 0.001). Increased CBD diameter also correlated with complex surgery with adjusted odds ratio of 1.5 (95% confidence interval: 1.10-2.06, P = 0.012) for each millimeter. The number of preoperative ERCPs and CBD diameter in choledocholithiasis patients are strong predictors of the need for open surgery and CBD exploration and should be considered in surgical planning and consent for patients requiring more than one ERCP procedure.

Evaluation of primary repair of common bile duct in common bile duct stones

Background Despite advancements in gallbladder surgery with the introduction of endoscopic and laparoscopic techniques, many surgeons, especially in the developing world, still perform open cholecystectomy with common bile duct (CBD) exploration for choledocholithiasis. Aim of the study The purpose of the study was to report the outcomes of open CBD exploration without the use of T-tubes. Materials and methods A prospective study of open CBD exploration and primary closure was performed without T-tube drainage. Preoperative investigations, the surgical techniques, and perioperative outcomes were recorded. Results Fifty patients had CBD exploration. In 45 patients this was performed by means of a supraduodenal choledochotomy, and in five of these patients free passage into the duodenum could not be achieved using catheters, irrigation, and dilators. These were completed with a choledochoduodenostomy. Conclusion In a limited resource setting, there is still a role for open CBD exploration and primary closure without the necessity of T-tubes and stents as evidenced by a good perioperative patient outcome.

A study of open surgical approach for common bile duct stones

Background: Common bile duct stones (CBDS) occur in 3-14 % of all the patients for whom cholecystectomy is performed. In this study we are presenting the experience of dealing with common bile duct stones by open surgical methods. The objective of the study was to study the open surgical approach for common bile duct stones. Methods: The study comprised of 162 cases admitted in surgical & medical wards at Osmania General Hospital and MRIMS, Hyderabad during the period from March 2010 to September 2015. Out of the 162 common bile duct calculi 100 cases were treated non-surgically and 62 cases were subjected to surgery. Results: Out of 62 cases 45 cases (72.5%) were subjected to open cholecystectomy, CBD exploration and T-tube drainage. In 10 cases (16.1%) patients underwent choledocho duodenostomy and in one case choledocho jejunostomy was performed. In 4 cases (6.4%) associated with choledochal cyst, hepatico jejunostomy was done, combined with excision of the cyst. Other 2 cases were of Mirrizi’s syndrome. Conclusions: Out of the 62 cases one died of cholangitis and rest of the patients survived. Our follow-up period varied from 1 year to 5 years.

The Surgical Management of Concomitant Gallbladder and Common Bile Duct Stones.

Background. The management of choledocholithiasis has evolved from open common bile duct exploration (OCBDE) to therapeutic endoscopic retrograde cholangiopancreatography (ERCP) to laparoscopic common bile duct exploration (LCBDE). Each entails a degree of difficulty. Aim. To review 5-year results of bile duct exploration in an UGI unit. Methods. Common bile duct explorations (CBDEs) performed between January 2008 and January 2013 were identified from a prospectively collected clinical audit system and results reviewed retrospectively. Results. 216 CBDEs were performed, 119 (55%) as an emergency and 52 (24%) following failed ERCP. Open CBDE (OCBDE) was performed primarily in 34/216 (16%) patients and attempted laparoscopically in 182 (84%). Fifty nine (32%) Laparoscopic CBDEs (LCBDEs) were converted to OCBDE. Of the remaining 123 LCBDEs, 51 (41%) primary choledochotomies and 72 (59%) primary transcystic CBDEs (TC-CBDEs) were performed. Forty nine (68%) TC-CBDEs were considered successful and 23 (32%) failed. Fifteen failed TC-CBDEs were converted to a successful laparoscopic choledochotomy. Ductal clearance was achieved in 187/216 (87%) patients and retained stones were identified in 20/123 (16%) LCBDEs. Complications occurred in 52/216 (24%) patients. There were 8/216 (4%) bile leaks requiring further intervention. Postoperative ERCP was carried out in 32/216 (15%) patients and 9/216 (4%) required relaparoscopy/laparotomy. No patient died. Conclusions. Successful management of choledocholithiasis requires a breadth of laparoscopic and endoscopic expertise.

Risk of Biliary Events After Selective Cholecystectomy During Biliopancreatic Diversion with Duodenal Switch.

Approximately 20 % of adults over 40 years of age in the USA develop cholelithiasis (Topart et al. Surg Obes Relat Dis. 9(4):526-30, 2013). Despite a higher incidence of biliary complications reported in postbariatric patients, it remains controversial whether simultaneous routine cholecystectomy should be performed during biliopancreatic diversion and duodenal switch (BPD/DS) or if a selective approach is more appropriate. The aim of this study was to evaluate incidence of biliary complications in patients who underwent BPD/DS without simultaneous cholecystectomy. Retrospective review of all patients who underwent BPD/DS between 2006 and 2012 was performed. A total of 361 consecutive patients were included in the study with mean age of 44.8 years (range 20-72), mean body weight of 317.2 lbs (range 205-547), and average body mass index (BMI) of 50.5 kg/m(2) (range 34-71.4). Ninety-seven patients were males (26.8 %). Out of 239 patients who still had their gallbladder after the BPD/DS, 52 patients (22.7 %) developed subsequent biliary symptoms (13 patients (5.4 %) in the first year, 25 (11 %) in the second year, and 14 (6.1 %) beyond the second year). During the study period, 40 patients eventually underwent elective laparoscopic cholecystectomy, and 11 had urgent cholecystectomy (9 laparoscopic and 2 open). One patient underwent open common bile duct exploration for ascending cholangitis. Average follow-up was 31 months (12-72 months) with follow-up rate of 95.6 % at 12 months and 92.8 % at 18 months. Leaving normal gallbladder in situ after BPD/DS is associated with an acceptable risk of biliary events. Risk of developing common bile duct stones is low; however, it may create treatment challenges.

Risk Factors Associated With Residual Stones in Common Bile Duct Via T Tube Cholangiography After Common Bile Duct Exploration.

Open surgery with common bile duct (CBD) exploration and T tube drainage are still traditionally performed in a large amount of selected patients with cholelithiasis and choledocholithiasis. Confirmation of CBD clearance via T tube cholangiography after surgery is a routine procedure before T tube removal. The present study aims at investigating potential risk factors associated with residual stones in CBD via T tube cholangiography.Patients undergoing open CBD exploration and T tube drainage for choledocholithiasis in the hospital were enrolled retrospectively from January 2011 to December 2013. The clinical data were reviewed and analyzed based on computer database. Patients undergoing laparoscopic CBD exploration were excluded. Patients with CBD exploration and primary choledochotomy or choledochojejunostomy were also excluded from the study. T tube cholangiography was regularly performed 4 to 8 weeks postoperatively.Two hundred seventy-five patients undergoing open CBD exploration and T tube drainage were enrolled in the study. Thirty-five patients (12.7%) were found to have gallbladder stones but without bile duct stones intraoperatively (Group A). One hundred sixty-five (Group B) and 77 patients (Group C) were diagnosed with choledocholithiasis and hepato-choledocholithiasis in operation, respectively. Disease of hepato-choledocholithiasis, size of the previous stones, and CBD exploration without intraoperative choledochoscopy were identified as risk factors associated with residue stones via T tube cholangiography (P < 0.001, P = 0.034, and P = 0.047, respectively). Patients with residual stones had a higher incidence of cholangitis during cholangiography than those without residual stones (8.9% vs 7.8%, P = 0.05). A scoring system based on the 3 risk factors has been set up. The incidence of residual stones were 5.6% in patients with score 0 to 1, 27.4% in patients with score 2 to 3 and 80.0% in patients with score 4 (P < 0.001). Abdominal distension after T tube clamp might be a strong predictor of cholangiography-associated choloangitis (P < 0.001).Intraopearative choledochoscopy should be strongly recommended as a routine procedure during CBD exploration to confirm the clearance of CBD, which could significantly lower the risk of residual stones postoperatively.