Laparoscopic Transcystic Common Bile Duct Exploration Research Articles

Laparoscopic transcystic common bile duct exploration versus transgastric endoscopic retrograde cholangiography during cholecystectomy after Roux-en-Y gastric bypass.

Treatment of common bile duct (CBD) stones after Roux-en-Y gastric bypass (RYGB) poses a particular challenge given the altered anatomy and inability to perform a standard endoscopic retrograde cholangiogram (ERC). The optimal treatment strategy for intraoperatively encountered CBD stones in post-RYGB patients has not been established. To compare outcomes following laparoscopic transcystic common bile duct exploration (LTCBDE) and laparoscopy-assisted transgastric ERC for CBDs during cholecystectomy in RYGB-operated patients. Swedish nationwide multi-registry study. The Swedish Registry for Gallstone Surgery and ERCs, GallRiks (n = 215,670), and the Scandinavian Obesity Surgery Registry (SOReg) (n = 60,479) were cross-matched for cholecystectomies with intraoperatively encountered CBD stones in patients with previous RYGB surgery between 2011 and2020. Registry cross-matching found 550 patients. Both LTCBDE (n = 132) and transgastric ERC (n = 145) were comparable in terms of low rates of intraoperative adverse events (1% versus 2%) and postoperative adverse events within 30 days (16% versus 18%). LTCBDE required significantly shorter operating time (P = .005) by on average 31 minutes, 95% confidence interval (CI) [10.3-52.6], and was more often used for smaller stones <4 mm in size (30% versus 17%, P = .010). However, transgastric ERC was more often used in acute surgery (78% versus 63%, P = .006) and for larger stones >8 mm in size (25% versus 8%, P < .001). LTCBDE and transgastric ERC have similarly low complication rates for clearance of intraoperatively encountered CBD stones in RYGB-operated patients, but LTCBDE is faster while transgastric ERC is more often used in conjunction with larger bile duct stones.

Sequential transcystic bile duct instrumentation, postoperative results in a high volume center

Background: Cholelithiasis is one of the most common and most demanding gastrointestinal affections regarding hospital expenses. Approximately 10-15% of these patients will present choledocholithiasis. At this moment, there is no general consensus about a therapeutic approach to common bile duct lithiasis. Different experts debate about an one-stage surgical approach (laparoscopic cholecistecomy (LC) and laparoscopic transcystic common bile duct exploration (LTCBDE) compared to a two-staged approach, combining LC and endoscopic retrograde colangio-pancreatography (ERCP).

Five-Year Experience with Transcystic Laparoscopic Common Bile Duct Exploration.

Background: Common bile duct (CBD) stones associated with cholecystitis can be treated by single-stage CBD exploration at the time of cholecystectomy or a two-stage approach with endoscopic stone extraction before or after cholecystectomy. The ideal management remains a matter of debate. The aim of this study is to analyze our outcomes with transcystic laparoscopic common bile duct exploration (LCBDE). Material and Methods: A retrospective review of patients who underwent transcystic LCBDE between 2015 and 2019 was performed. Results: A total of 106 patients underwent transcystic LCBDE over 5 years. We performed 1192 laparoscopic cholecystectomies with cholangiograms from March 2015 to December 2019. Fifteen patients had a preoperative endoscopic retrograde cholangiopancreatography (ERCP) for CBD stones seen on magnetic resonance cholangiopancreatography that during laparoscopic cholecystectomy with intraoperative cholangiogram (IOC), there were stones and/or sludge found in the CBD, which required clearance through a transcystic approach. Of the 91 patients who did not have a preoperative ERCP, clearance of the CBD was successful through a transcystic approach in 78 patients (86%). In the 13 patients that intraoperative clearance was not achieved (n = 13, 14%), a postoperative ERCP was performed. A total of 28 patients underwent either pre- or postoperative ERCP (n = 28, 26%). Choledochotomy was not performed in any of the patients. The mean operative time was 127 minutes (127 ± 48). The mean hospital length of stay (LOS) was 4 days (3.9 ± 2.8) with a median LOS of 3 days. Complications observed include wound infection (n = 2, 2%), pancreatitis after ERCP (n = 1, 1%), pneumonia (n = 1, 1%), and right hepatic duct injury (n = 1, 1%). Conclusion: Transcystic LCBDE is an effective and safe option for treatment of CBD stones. While a transcystic approach does not guarantee clearance of the CBD, it avoids the morbidity associated with a choledochotomy and can often prevent patients from having to undergo an additional procedure.

Evaluation of therapeutic efficacy, safety and economy of ERCP and LTCBDE in the treatment of common bile duct stones.

Objectives: This study further compared the endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic transcystic common bile duct exploration (LTCBDE) approaches in the treatment of common bile duct stones (CBDS) from the perspective of efficacy, safety and economy. Methods: The therapeutic efficacy and safety of ERCP and LTCBDE approaches were retrospectively compared. Cost-effectiveness analysis of clinical economics was performed to analyze and evaluate the two approaches. Results: There was no significant difference in the success rate of surgery and bile stone residue between ERCP and LTCBDE group. The incidence of postoperative complications in ERCP group was significantly higher than that in the LTCBDE group; while the incidence of pancreatitis in the ERCP group was significantly higher than that in the LTCBDE group. There was no significant difference in biliary infection, bile leakage and sepsis between ERCP and LTCBDE groups. In terms of cost, the costs of surgery and nursing were significantly lower, the costs of treatment and sanitary materials were significantly higher in the ERCP group than that in the LTCBDE group. There was no significant difference in the costs of medical examination, laboratory test, medicine cost and total cost between ERCP group and LTCBDE group. The total length of hospital stay, length of hospital stay before surgery and duration of surgery in the ERCP group were significantly lower than that in the LTCBDE group; there was no significant difference in length of hospital stay after surgery between the ERCP and LTCBDE group. The cost-effectiveness ratio of ERCP group was 34171.25, and the cost-effectiveness of LTCBDE group was 34524.25. The incremental cost-effectiveness ratio (ICER) of the two groups was 51415. Conclusion: ERCP and LTCBDE approaches had similar therapeutic efficacy in the treatment of CBDS. The safety of LTCBDE approach is superior to that of ERCP approach for the treatment of CBDS. ERCP approach is more economical in the treatment of CBDS than LTCBDE approach.

Laparoscopic transcystic common bile duct exploration in patients with a nondilated common bile duct.

Laparoscopic transcystic common bile duct exploration (LTCBDE) is the minimally traumatic surgical method for the treatment of choledocholithiasis secondary to cholecystolithiasis with dilated common bile duct (CBD). However, no report exists concerning LTCBDE in patients with nondilated CBD. The purpose of this study was thus to explore the safety, efficacy, and feasibility of LTCBDE in patients with choledocholithiasis secondary to cholecystolithiasis with nondilatation of the CBD. We retrospectively analyzed 47 patients with choledocholithiasis secondary to cholecystolithiasis who were treated with LTCBDE at the Second Affiliated Hospital of Nanchang University from January 2017 to August 2021 (all the patients had undergone endoscopic retrograde cholangio-pancreatography treatment, but this failed due to various reasons). Clinical data on disease characteristics, methods for cystic duct incision and CBD stone extraction, and surgical outcomes were collected and reviewed. Each patient was followed up for more than 3 months. There were 47 patients in this study, including 21 females and 26 males, with their ages ranging from 15 to 82 years (51±15 years). All patients were treated with surgery, and the CBD stones were removed successfully. Among these patients, 45 underwent LTCBDE for the removal of stones in the CBD, with failure occurring in 2 patients who then accepted laparoscopic common bile duct stone removal (LCBDE) + T tube drainage. The diameter of the cystic duct was 0.30-0.73 cm (0.60±0.07 cm), the diameter of the CBD was 0.60-0.80 cm (0.73±0.05 cm), the operation time was 75-220 minutes (159±33 minutes), and the postoperative hospital stay was 2-13 days (6±2 days). None of the patients experience any serious postoperative complications, and all were discharged safely. During the follow-up, no postoperative biliary stenosis, bile leakage, or other complications occurred. LTCBDE is feasible to treat patients with choledocholithiasis secondary to cholecystolithiasis with nondilatation of the CBD. This choice of treatment plan reduces the length of hospital stay and the occurrence of postoperative complications. However, it is recommended that this be attempted on the basis of the experience of LTCBDE with dilated CBD.

Surgical methods of treatment for cholecystolithiasis combined with choledocholithiasis: six years’ experience of a single institution

IntroductionThe optimal treatment of choledocholithiasis combined with cholecystolithiasis remains controversial. Common surgical methods vary among endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC), laparoscopic transcystic common bile duct exploration (LTCBDE), laparoscopic transductal common bile duct exploration (LCBDE) with or without T-tube drainage. The purpose of this study is to evaluate the safety and effectiveness of surgical methods and to determine the appropriate procedure for patients with cholecystolithiasis combined with choledocholithiasis.MethodsFrom January 2013 to January 2019, a total of 1555 consecutive patients diagnosed with cholecystolithiasis combined with choledocholithiasis who underwent surgical treatment in Tongji Hospital were retrospectively analyzed. Total 521 patients with intrahepatic bile duct stones underwent LC + LCBDE + T-Tube were excluded from the analysis. At last, 1034 patients who met the inclusion criteria were divided into three groups according to their surgical methods: preoperative ERCP + subsequent LC (ERCP + LC group, n = 275), LC + LCBDE + intraoperative endoscopic nasobiliary drainage (ENBD) + primary duct closure (Tri-scope group, n = 479) and LC + laparoscopic transcystic CBD exploration (LTCBDE group, n = 280). Clinical records, operative findings and postoperative follow-up were collected and analyzed.ResultsThere was no mortality in three groups. Common bile duct (CBD) stone clearance rate was 97.5% in ERCP + LC group, 98.7% in Tri-scope group, and 99.3% in LTCBDE group. There were no difference in terms of demographic characteristics, biochemistry findings and presentations, but the Tri-scope group had the biggest diameter and amount of stones and diameter of CBD, the LTCBDE group had the least CBD stones and the biggest diameter of cystic gall duct (CGD). ERCP + LC group have the longest hospital stay (14.16 ± 3.88 days vs 6.92 ± 1.71 days vs 10.74 ± 5.30 days, P < 0.05), also has the longest operative time than others (126.08 ± 42.79 min vs 92.31 ± 10.26 min, 99.09 ± 8.46 min, P < 0.05). Compared to ERCP + LC group, LTCBDE group and Tri-scope group had lower postoperation-leukocyte, shorter surgery duration and hospital stay (P < 0.05). Compared to the Tri-scope group, the LTCBDE group had the shorter hospital stay, extubation time and operation time and less intraoperative bleeding. There were less postoperative complications in LTCBDE group (1.1%) compared to the ERCP + LC group (3.6%) and Tri-scope group (2.2%). Follow-up time was 6 to 72 months. Four patients in ERCP + LC group and 5 in Tri-scope group reported recurrent stones.ConclusionAll the three surgical methods are safe and effective. Tri-scope approach and LTCBDE approach have superiority to preoperative ERCP + LC. LC + LTCBDE shows priority over Tri-scope approach, but should be performed in selected patients. LC + LCBDE + T-Tube can be an alternative management if the other three procedures were failed. The surgeons should choose the most appropriate surgical procedure according to the preoperative examination results and intraoperative situation.

Laparoscopic transcystic common bile duct exploration as treatment for choledocholithiasis after Roux-en-Y gastric bypass.

Treatment of choledocholithiasis after Roux-en-Y gastric bypass (RYGB) is a therapeutic challenge given the altered anatomy. To overcome this technical difficulty, different modified endoscopic approaches have been described but significant morbidity accompanies these procedures. The aim of the present study is to report our experience with laparoscopic transcystic common bile duct exploration (LTCBDE) as treatment of choledocholithiasis after RYGB. This is a retrospective cohort study of 854 consecutive patients with RYGB at a single institution between January 2007 and December 2019. Our study population focused on patients who developed biliary events after RYGB. Demographic data and perioperative parameters were compared between patients who underwent laparoscopic cholecystectomy (LC) after RYGB with (defined as Group A) and without (defined as Group B) LTCBDE. Fifty-seven (8.93%) patients developed a biliary event after RYGB that led to LC. Of those, 11 (19.2%) presented choledocholithiasis during intraoperative cholangiogram and were simultaneously treated with LTCBDE (Group A). Choledocholithiasis was unsuspected in the preoperative setting in 7 (63.6%) of the 11 patients. The procedure was successful in 90.9% (n = 10). Comparing Group A and B, no statistically significant differences were found regarding age, gender, length of hospital stay, and morbidity (p > 0.05). Mean operative time of Group A was 113.1min, adding, on average, 35min to LC (113.1min vs 77.9min, p = 0.004). LTCBDE offers an effective approach for common bile duct stones in patients who underwent RYGB. This procedure did not add significant length of hospital stay nor morbidity to laparoscopic cholecystectomy.

Long Term Outcomes of Trans-Cystic Bile Duct Exploration

Introduction: Laparoscopic transcystic common bile duct exploration (LTCBDE) at the time of cholecystectomy for choledocholithasis negates the need for endoscopic retrograde cholangiopancreatography (ERCP), along with its associated complications and cost. The aim of this study was to assess the long-term outcomes associated with TCBDE. Methods: Patients undergoing LTCBDE at the Royal Brisbane Hospital between 1995 and 2019 were retrospectively analysed. LTCBDE was performed using a 5.5-Fr wire basket kit (Cook Australia) under fluoroscopic guidance. Satisfactory completion of the CBD exploration was confirmed by completion cholangiography. Patients had clinical follow up post discharge. Data were analysed using R statistics with a p< 0.05 considered significant. Results: 397 patients underwent LTCBDE, with 262 females. The median age was 52 years old (range 16-88). Median follow up was 5.4 years, and the median length of hospital stay was 1 day (range 0 - 28). 28 patients (7.1%) required postoperative ERCP for failure of complete stone clearance at LTCBDE. Two patients developed mild acute pancreatitis postoperatively after successful duct clearance. Four patients (1%) required ERCP following discharge post LTCBDE, after representing with symptomatic choledocholithiasis. Overall, 91.9% of patients had successful bile duct clearance with LTCBDE. Cost analysis comparing LTCBDE with the average cost of patients undergoing ERCP followed by laparoscopic cholecystectomy showed LTCBDE to be significantly less (p< 0.05). Conclusion: Upfront laparoscopic CBDE is now a well-established practice at this unit. This study reports a high rate of bile duct stone clearance with LTCBDE, with minimal complications and obvious cost benefits.

The ABCdE score for PREdicting Lithotripsy Assistance during transcystic Bile duct Exploration by Laparoendoscopy (PRE-LABEL).

Common bile duct (CBD) stones are reported in ~ 15% of patients who undergo laparoscopic cholecystectomy for symptomatic gallstones. Prior to lithotripsy techniques, transcystic laparoscopic common bile duct exploration (LCBDE) was limited to smaller CBD stones. The addition of lithotripsy to LCBDE increases cost, operative time and staffing requirements. Predicting which patients might require lithotripsy would be useful in operative planning. The primary aim was to investigate clinical variables for predicting lithotripsy assistance during transcystic bile duct exploration by laparoendoscopy (PRE-LABEL). Secondary aims were to develop and validate a predictive scoring tool. A retrospective review of a prospectively collected database of consecutive patients who underwent transcystic LCBDE at a single centre in the UK was performed to investigate clinical variables for PRE-LABEL and develop a scoring tool (ABCdE score: age, bilirubin, CBD diameter, ERCP). Binary logistic regression was used to investigate which independent variables (predictors) were associated with lithotripsy assistance during transcystic LCBDE. The ABCdE score was applied to both UK and Spain patient cohorts to determine its sensitivity, specificity and accuracy. From 8 pre-operative clinical variables analysed, age ≤ 40years, bilirubin > two-times upper limit of normal, CBD diameter ≥ 10mm and ERCP failure of stone extraction were independent predictors of requiring lithotripsy during transcystic LCBDE and formed the ABCdE score. The hazard ratios were 2.87, 3.79, 2.78 and 10.06, respectively. An ABCdE score ≥ 2 resulted in 71% sensitivity, 81% specificity and 79% accuracy in predicting lithotripsy during LCBDE (UK cohort). Validation using a contemporary cohort from Spain yielded similar sensitivity, specificity and accuracy. This study represents the only study to date reporting independent predictors of requiring lithotripsy assistance during transcystic LCBDE. ABCdE score ≥ 2 can highlight patients that may require lithotripsy in order to avoid failure of transcystic LCBDE and therefore avoid choledochotomy or post-operative ERCP.

Laparoscopic transcystic common bile duct exploration (LTCBDE): a safer method to treat common bile duct stones than laparoscopic choledochotomy.

We read the article published in the Spanish Journal of Gastroenterology and its accompanying editorial about the laparoscopic treatment of both cholecystolithiasis and choledocholithiasis in a single stage procedure. We would like to make some comments. Common bile duct (CBD) stones can lead to serious complications such as cholangitis and pancreatitis. So far, there is no standard surgical treatment for choledocholithiasis. Although, there are some ways to deal with CBD stones. Each method has its own advantages and disadvantages. In the era of advancements in minimally invasive technology, the treatment of CBD stones still remains controversial with regard to endoscopic retrograde cholangiopancreatography (ERCP) or laparoscopic common bile duct exploration (LCBDE). Preoperative ERCP followed by laparoscopic cholecystectomy (LC) is frequently performed.

Holmium laser lithotripsy improves the rate of successful transcystic laparoscopic common bile duct exploration

PurposeTranscystic laparoscopic common bile duct exploration (LCBDE) seems safer than transductal LCBDE and is associated with fewer biliary complications. It has traditionally been limited to smaller bile duct stones however. This study aimed to assess the ability of laser-assisted bile duct exploration by laparoendoscopy (LABEL) to increase the rate of successful transcystic LCBDE in patients with bile duct stones at the time of laparoscopic cholecystectomy.MethodsPatients undergoing LCBDE between 2014 and 2018 were retrospectively analysed. Baseline demographic and medical characteristics were recorded, as well as intra-operative findings and post-procedure outcomes. Standard LCBDE via the transcystic route was initially attempted in all patients, and LABEL was only utilised if there was failure to achieve transcystic duct clearance. The transductal route was utilised for failed transcystic extraction.ResultsOne hundred and seventy-nine consecutive patients underwent LCBDE; 119 (66.5%) underwent unaided transcystic extraction, 29 (16.2%) required LABEL to achieve transcystic extraction and 31 (17.3%) failed transcystic extraction (despite the use of LABEL in 7 of these cases) and hence required conversion to transductal LCBDE. As such, LABEL could be considered to increase the rate of successful transcystic extraction from 66.5% (119/179) to 82.7% (148/179). Patients requiring LABEL were however more likely to experience major complications (CD III–IV 5.6% vs 0.7%, p = 0.042) although none were specifically attributable to the laser intra-operatively.ConclusionsLABEL is an effective adjunct to LCBDE that improves the rate of successful transcystic extraction.

Protocol for the CREST Choles (Chinese REgistry Study on Treatment of Cholecysto-Choledocholithiasis) study: an ambispective, multicenter, observational, open-cohort study

IntroductionThe best approach for choledocholithiasis remains a matter of debate. Choledocholithiasis is usually treated with endoscopic sphincterotomy (EST), laparoscopic common bile duct exploration (LCBDE) or laparoscopic transcystic common bile duct...

Long-Term Prognosis of Cholecystocholedocholithiasis in Chinese Population

Introduction: Choledocholithiasis is usually treated with endoscopic sphincterotomy (EST), laparoscopic common bile duct exploration (CBDE) (LCBDE), or laparoscopic transcystic CBDE (LTCBDE). However, the comparative long-term prognosis of these methods in terms of adverse outcomes remains uncertain. Methods: In an ambispective, multicenter, observational, open cohort study, patients with cholecystocholedocholithiasis underwent one of three treatments (EST+laparoscopic cholecystectomy (LC), LCBDE+LC, and LTCBDE+LC).The primary outcome was adverse outcomes. Results: At a median follow-up period of 2.72 years among 2708 patients, the adverse outcome rate is 9.3%. Compared with LCBDE and LTCBDE groups, EST group displayed an increased risk for adverse outcomes (HR 1.25, 95% CI 0.93-1.69, P=0.146; HR 1.77, 95% CI 1.30-2.43, P<0.001) and stone-related outcomes (HR 1.43, 95% CI 0.99-2.06, P=0.054; HR 4.36, 95% CI 2.71-7.02, P<0.001) in the unadjusted Cox model. After adjustment in the multivariable analysis, EST group still displayed an increased risk of adverse outcomes (HR 1.43, 95% CI 1.05-1.95, P=0.021; HR 1.87, 95% CI 1.35-2.59, P<0.001) and stone-related outcomes (HR 1.64, 95% CI 1.13-2.37, P=0.010; HR 4.88, 95% CI 2.99-7.97, P<0.001). Compared with LTCBDE group, LCBDE group displayed an increased risk for a stone-related outcome in both the unadjusted Cox model (HR 3.05, 95% CI 1.89-4.90, P<0.001) and the adjusted multivariable analysis (HR 2.98, 95% CI 1.83-4.86, P <0.001). Conclusion: Compared with EST, the laparoscopic technique was associated with a lower risk of adverse outcomes and stone-related outcomes after adjustment for confounding factors. In laparoscopic techniques, the risk of stone-related outcomes after LTCBDE is reduced 66.4% than LCBDE. Clinical Trial Registration: CREST Choles ClinicalTrials.gov number, NCT02554097. Funding Statement: The author(s) disclose receipt of the following financial support for the research, authorship, and/or publication of this article: this program is sponsored by Capital Health Research and Special Development (No. 2016-1-1111), National Key Technologies R&D Program (No. 2015BAI13B09), and Beijing Municipal Administration of Hospitals Incubator Program (No. PX2016001 and No. PX2019004). Declaration of Interests: The author(s) declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Ethics Approval Statement: Ethical approval was obtained at all participating centers.

Comparative study between laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for choledocholithiasis

Background: Endoscopic retrograde cholangiopancreatography (ERCP) with consequent laparoscopic cholecystectomy (LC) has been the favored approach for the treatment of choledocholithiasis for a long time; however recently, laparoscopic common bile duct exploration (LCBDE) has been offered to patients with suspected choledocholithiasis. Objective and aim of this work was to compare the efficacy, safety, and the surgical outcomes of LCBDE with ERCP followed by LC and determine the most appropriate approach for patients with choledocholithiasis.Methods: A prospective clinical study was carried out from March 2017 to September 2018. It included 50 patients with cholecysto-choledocholithiasis who were divided into two groups: group A (25 patients) included patients who underwent transcystic LCBDE and stone extraction with LC in one stage, and group B (25 patients) included patients who underwent ERCP followed by LC in two stages. The common bile duct (CBD) stone clearance rate, postoperative bile leakage, postoperative morbidity, mortality, overall hospital stay, and patient satisfaction were analyzed.Results: LCBDE and ERCP+LC were similar in terms of clearance rate, operative time, postoperative complications, retained CBD stones, and postoperative length of stay, but there was a significant difference in number of procedures and patient satisfaction.Conclusions: Although both approaches have equivalent success rates, LCBDE is better in terms of fewer procedures, and better satisfaction compared with ERCP + LC. Our study suggests that one-stage management is the treatment of choice for patients with cholecysto-choledocholithiasis.

Laparoscopic Transcystic Common Bile Duct Exploration in the Emergency Is as Effective and Safe as in Elective Setting

BackgroundEmergent laparoscopic transcystic common bile duct exploration (LTCBDE) has been reported to be on the increase in some institutions, reflecting the growing confidence with the technique. However, no study has focused on the outcomes of LTCBDE in the non-elective setting. The aim of this study is to investigate whether LTCBDE can be performed effectively and safely in the emergency. MethodsThis is a retrospective study of 500 consecutive patients with choledocholithiasis subjected for LTCBDE at the Hospital Italiano de Buenos Aires from January 2009 to January 2018. Procedures were classified according to the setting as emergent or elective. Demographic data and perioperative parameters were compared between groups. ResultsThroughout the period comprised, 500 patients were admitted for choledocholithiasis and gallstones. A single-step treatment combining LTCBDE and laparoscopic cholecystectomy was attempted: 211 (42.2%) were performed electively and the 289 (57.8%) as an emergency. There was no significant difference in the success rate of LTCBDE (93.9% versus 93.8%, p = 0.975) for the two groups. The operative time was slightly longer in the emergency group (122 ± 63 versus 106 ± 53 min, p = 0.002). Postoperative recovery was slower in the emergency group, as reflected by a higher rate of prolonged postoperative stay (21.1% vs 5.7%, p < .001). The rates of postoperative complications were similar between groups (2.8% vs 5.9%, p = 0.109). ConclusionEmergent LTCBDE can be performed with equivalent efficacy and morbidity when compared to an elective procedure. Patients undergoing emergent procedures have longer procedures and hospital stays.

Laparoscopic transcystic common bile duct exploration: surgical indications and procedure strategies

LTCBDE combined with or without modified techniques is safe and efficacious for the management of gallstones and concomitant, even large, common bile duct (CBD) stones. To describe the surgical indications and procedure strategies of laparoscopic transcystic common bile duct exploration (LTCBDE), a retrospective analysis of 205 patients with concomitant gallstones and CBD stones treated using LTCBDE between June 2008 and June 2015 was performed. Clinical data on disease characteristics, methods for cystic duct incision and CBD stone extraction (with or without laser lithotripsy), and surgical outcomes were collected and reviewed. CBD stones were successfully cleared in all patients. No patient was converted to choledochotomy or laparotomy. The cystic duct diameter ranged 3-8mm, and 85 patients with cystic duct diameter ≥ 5mm. The mean time for CBD stone extraction was 25.3min, with the operative time ranged from 63 to 170min. Lithotripsy was used in 74 (36.1%) patients among which 26 patients with cystic duct diameter ≥ 5mm. Estimated blood loss during surgery was 10-120ml per patient, and no intra-operative blood transfusions were needed. The mean postoperative hospital stay was 5.1 (range 3-7) days, and postoperative complications developed in seven patients. No bile duct injury, stricture, remnant, recurrent stones, or other adverse events were observed during the mean follow-up of 8 months. Based on preoperative MRCP and intra-operative IOC findings about cystic duct diameter, the diameter of CBD, CBD stone size, we summarized and proposed the surgical indications and suitable techniques and strategies during LTCBDE.

Predictors of Failed Transcystic Laparoscopic Common Bile Duct Exploration: Analysis of Multicenter Integrated Health System Database.

The aim of this study is to report our experience with laparoscopic common bile duct exploration (LCBDE) and validate the experts' opinion about anatomical predictors of failed transcystic LCBDE (TLCBDE) approach. Patients undergoing LCBDE at Kaiser Permanente Southern California hospitals (2005-2015) were included. Predictors of failed TLCBDE were identified using bivariate analysis. Of 115 LCBDE, 89.6% were TLCBDE and 10.4% through choledochotomy. Success rate, morbidity, and length of hospital stay were 83.5%, 6.1%, and 3.8 days respectively. Only stone size:cystic duct ratio >1 (35% versus 63%, P = .044) was associated with failure of TLCBDE. In accordance with experts' opinion, there was a suggestive association of stone size ≥6 mm, cystic duct ≤4 mm, multiple stones, and proximal stone location with failure; however, these did not reach statistical significance. LCBDE is an effective and safe mean of clearing common bile duct stones at community hospitals of an integrated health system. Previously cited contraindications for TLCBDE are not absolute, but rather predictors of failure.

Acute Pancreatitis After Laparoscopic Transcystic Common Bile Duct Exploration: An Analysis of Predisposing Factors in 447 Patients.

In laparoscopic transcystic common bile duct exploration (LTCBDE), the risk of acute pancreatitis (AP) is well recognized. The present study assesses the incidence, risk factors, and clinical impact of AP in patients with choledocholithiasis treated with LTCBDE. A retrospective database was completed including patients who underwent LTCBDE between 2007 and 2017. Univariate and multivariate analyses were performed by logistic regression. After exclusion criteria, 447 patients were identified. There were 70 patients (15.7%) who showed post-procedure hyperamylasemia, including 20 patients (4.5%) who developed post-LTCBDE AP. Of these, 19 were edematous and one was a necrotizing pancreatitis. Patients with post-LTCBDE AP were statistically more likely to have leukocytosis (p < 0.004) and jaundice (p = 0.019) before surgery and longer operative times (OT, p < 0.001); they were less likely to have incidental intraoperative diagnosis (p = 0.031) or to have biliary colic as the reason for surgery (p = 0.031). In the final multivariate model, leukocytosis (p = 0.013) and OT (p < 0.001) remained significant predictors for AP. Mean postoperative hospital stay (HS) was significantly longer in AP group (p < 0.001). The risk of AP is moderate and should be considered in patients with preoperative leukocytosis and jaundice and exposed to longer OT. AP has a strong impact on postoperative HS.

Laparoscopic ultrasonography in surgical treatment of secondary choledocholithiasis

Objective To investigate the diagnostic accuracies among laparoscopic ultrasonography (LUS), CT, MRCP and transabdominal ultrasonography in secondary choledocholithiasis, and to compare the procedural efficacy of LUS carried out by surgeons assisted by ultrasound physicians, and by surgeons alone. Methods Forty-two patients underwent laparoscopic transcystic common bile duct exploration (LTCBDE) in Beijing Luhe Hospital, Capital Medical University. All these patients underwent LUS examination. In 26 patients, LUS was carried out by surgeons alone while in 16 patients it was assisted by ultrasound physicians. The results of intraoperative choledochoscopy were used to verify the results in the two groups in scan time, and in its accuracies when compared with CT, MRCP and preoperative abdominal ultrasound. Results The accuracy of LUS was 92.9%, which was significantly better than that of CT (73.8%) and transabdominal ultrasonography (23.8%, P 0.05). Surgeons alone were faster than ultrasound physicians in performing LUS [(8.5±3.0) min vs (13.2±4.6) min, P 0.05). Conclusion LUS diagnosed common bile duct stones by surgeons who had adequate ultrasound training, with a high accuracy rate and good efficiency. Key words: Laparoscopic ultrasound; Secondary choledocholithiasis; Bile duct exploration

Acute pancreatitis after laparoscopic trans-cystic common bile duct exploration (LTCBDE): An analysis in 447 consecutive patients

Acute pancreatitis after laparoscopic trans-cystic common bile duct exploration (LTCBDE): An analysis in 447 consecutive patients