Outcomes of endoscopic sphincterotomy vs open choledochotomy for common bile duct stones

BACKGROUND Endoscopic sphincterotomy(EST) for the management of common bile duct stones(CBDS) is used increasingly widely because it is a minimally invasive procedure. However, some clinical practitioners argued that EST may be complicated by post-endoscopic retrograde cholangiopancreatography(ERCP)pancreatitis(PEP) and accompanied by a higher recurrence of CBDS than open choledochotomy(OCT). Whether any differences in outcomes exist between these two approaches for treating CBDS has not been thoroughly elucidated to date.AIM To compare the outcomes of EST vs OCT for the management of CBDS and to clarify the risk factors associated with stone recurrence.METHODS Patients who underwent EST or OCT for CBDS between January 2010 and December 2012 were enrolled in this retrospective study. Follow-up data were obtained through telephone or by searching the medical records. Statistical analysis was carried out for 302 patients who had a follow-up period of at least 5 years or had a recurrence. Propensity score matching(1:1) was performed to adjust for clinical differences. A logistic regression model was used to identify potential risk factors for recurrence, and a receiver operating characteristic(ROC)curve was generated for qualifying independent risk factors.RESULTS In total, 302 patients undergoing successful EST(n = 168) or OCT(n = 134) were enrolled in the study and were followed for a median of 6.3 years. After propensity score matching, 176 patients remained, and all covariates were balanced. EST was associated with significantly shorter time to relieving biliary obstruction, anesthetic duration, procedure time, and hospital stay than OCT(P <0.001). The number of complete stone clearance sessions increased significantly in the EST group(P = 0.009). The overall incidence of complications and mortality did not differ significantly between the two groups. Recurrent CBDS occurred in18.8%(33/176) of the patients overall, but no difference was found between the EST(20.5%, 18/88) and OCT(17.0%, 15/88) groups. Factors associated with CBDS recurrence included common bile duct(CBD) diameter > 15 mm(OR =2.72; 95%CI: 1.26-5.87; P = 0.011), multiple CBDS(OR = 5.09; 95%CI: 2.58-10.07; P< 0.001), and distal CBD angle ≤ 145°(OR = 2.92; 95%CI: 1.54-5.55; P = 0.001). The prediction model incorporating these factors demonstrated an area under the receiver operating characteristic curve of 0.81(95%CI: 0.76-0.87).CONCLUSION EST is superior to OCT with regard to time to biliary obstruction relief, anesthetic duration, procedure time, and hospital stay and is not associated with an increased recurrence rate or mortality compared with OCT in the management of CBDS.

Comparative quality of life study between endoscopic sphincterotomy and surgical choledochotomy

AIM: To determine quality of life improvement in choledocholithiasis patients who underwent endoscopic sphincterotomy (EST) versus open choledochotomy (OCT).

Laparoscopic common bile duct exploration to treat choledocholithiasis in situs inversus patients:A technical review

Situs inversus(SI)is a rare congenital condition characterized by a mirror-image transposition of the major visceral organs.Since the 1990s,more than one hundred SI patients have been reported to have successfully undergone laparoscopic cholecystectomy.In these cases,the major problem is to overcome is the left-right condition for right-handed surgeons.Laparoscopic common bile duct exploration(LCBDE),an alternative to treat patients with bile duct stones,has shown equivalent efficacy and is less likely to cause pancreatitis than endoscopic retrograde cholangiopancreatography.Recent updated meta-analyses revealed that a shorter postoperative hospital stay,fewer procedural interventions,cost-effectiveness,a higher stone clearance rate,and fewer perioperative complications are additional advantages of LCBDE.However,the technique is technically demanding,even for skilled laparoscopic surgeons.Conducting LCBDE in patients with difficult situations,such as SI,is more complex than usual.We herein review published SI patients with choledocholithiasis treated by LCBDE,including our own experience,and this paper focuses on the technical aspects.

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

Background:Laparoscopic common bile duct exploration(LCBDE)is one of the minimally invasive options for choledocholithiasis.Primary closure of the common bile duct(CBD)upon completion of laparoscopic choledochotomy is safe in selected patients.The present study aimed to evaluate the feasibility and safety of primary closure of CBD after LCBDE in patients aged 70 years or older.Methods:A total of 116 patients(51 males and 65 females)who suffered from choledocholithiasis and underwent primary closure of the CBD(without T-tube drainage)after LCBDE from January 2003 to December 2017 were recruited.They were classified into two groups according to age:group A(≥70 years,n=56),and group B(<70 years,n=60).The preoperative characteristics,intraoperative details,and postoperative outcomes of the two groups were evaluated.Results:The mean operative time was 172.02 min for group A and 169.92 min for group B(P=0.853).The mean hospital stay was 7.40 days for group A and 5.38 days for group B(P<0.001).Bile leakage occurred in two patients in group A and one in group B(3.57%vs 1.67%,P=0.952).There were no significant differences in the rates of postoperative complications and mortality between the two groups.At median follow-up time of 60 months,stone recurrence was detected in one patient in group A and two in group B(1.79%vs 3.33%,P=1.000).Stenosis of CBD was not observed in group A and slight stenosis in one patient in group B(0 vs 1.67%,P=1.000).Conclusion:Primary closure of the CBD upon completion of laparoscopic choledochotomy is safe and feasible in elderly patients≥70 years old.

Innovative technique of needlescopic grasper-assisted single-incision laparoscopic common bile duct exploration:A comparative study

AIM: To investigate the safety and feasibility of needlescopic grasper-assisted single-incision laparoscopic common bile duct exploration(n SIL-CBDE) by comparing the surgical outcomes of this technique with those of conventional laparoscopic CBDE(CL-CBDE).METHODS: We retrospectively analyzed the clinical data of patients who underwent CL-CBDE or n SILCBDE for the treatment of common bile duct(CBD) stones between January 2000 and December 2014. For performing n SIL-CBDE, a needlescopic grasper was also inserted through a direct puncture below the right subcostal line after introducing a single-port through the umbilicus. The needlescopic grasper helped obtain the critical view of safety by retracting the gallbladder laterally and by preventing crossing or conflict between laparoscopic instruments. The gallbladder was then partially dissected from the liver bed and used for retraction. CBD stones were usually extracted through a longitudinal supraduodenal choledochotomy, mostly using flushing a copious amount of normal saline througha ureteral catheter. Afterward, for the certification of CBD clearance, CBDE was performed mostly using a flexible choledochoscope. The choledochotomy site was primarily closed without using a T-tube, and simultaneous cholecystectomies were performed.RESULTS: During the study period, 40 patients underwent laparoscopic CBDE. Of these patients, 20 underwent CL-CBDE and 20 underwent n SIL-CBDE. The operative time for n SIL-CBDE was significantly longer than that for CL-CBDE(238 ± 76 min vs 192 ± 39 min, P = 0.007). The stone clearance rate was 100%(40/40) in both groups. Postoperatively, the n SIL-CBDE group required less intravenous analgesic(pethidine)(46.5 ± 63.5 mg/kg vs 92.5 ± 120.1 mg/kg, P = 0.010) and had a shorter hospital stay than the CL-CBDE group(3.8 ± 2.0 d vs 5.1 ± 1.7 d, P = 0.010). There was no significant difference in the incidence of postoperative complications between the two groups.CONCLUSION: The results of this study suggest that n SIL-CBDE could be safe and feasible while improving cosmetic outcomes when performed by surgeons trained in conventional laparoscopic techniques.

Cholecysto-choledochostomy plus construction of subcutaneous cholecystic tunnel in treatment of choledocholith

OBJECTIVE: To avoid the pitfalls of choledochotomy with T-tube drainage in the treatment of choledocholith. METHODS: A novel operation was designed as cholecysto-choledochostomy plus construction of subcutaneous cholecystic tunnel. After the common bile duct was cut open and stones were removed, the gallbladder was appropriately dissociated and the cholecystic ampulla was incised. Then, the incision of the cholecystic ampulla was anastomosed to the opened common bile duct, and the cholecystic fundus was fixed out of the abdominal muscular stratum. RESULTS: Twenty-one patients with choledocholith underwent this operation successfully and recovered well without postoperative complications. One of them was diagnosed as having recurrent stones in 2 years and 3 months after operation. Consequently, the subcutaneous cholecystic tunnel was opened under local anesthesia to remove successfully the stones with choledochoscope. CONCLUSION: This operation provides a convenient way to remove postoperative recurrent stones with choledochoscope and avoid receliotomy.

Clinical observation of laparoscopic cholecystectomy combined with endoscopic retrograde cholangiopancreatography or common bile duct lithotripsy

BACKGROUND The incidence of common bile duct(CBD) stones accounts for approximately 10%–15% of all CBD diseases.Approximately 8%–20% of these patients also have gallstones with heterogenous signs and symptoms.AIM To investigate the clinical effects of laparoscopic cholecystectomy(LC) combined with endoscopic retrograde cholangiopancreatography(ERCP) and LC with CBD excision and stone extraction in one-stage suture(LBEPS) for the treatment of gallbladder and CBD stones.METHODS Ninety-four patients with gallbladder and CBD stones were selected from our hospital from January 2018 to June 2021.They were randomly divided into study and control groups with 47 patients each.The study group underwent LC with ERCP,and the control group underwent LC with LBEPS.Surgery,recovery time of gastrointestinal function,complication rates,liver function indexes,and stress response indexes were measured pre-and postoperatively in both the groups.RESULTS The durations of treatment and hospital stay were shorter in the study group than in the control group.There was no significant difference between the one-time stone removal rate between the study and control groups.The time to anal evacuation,resumption of oral feeding,time to bowel sound recovery,and time to defecation were shorter in the study group than in the control group.The preoperative serum direct bilirubin(DBIL),total bilirubin(TBIL),and alanine aminotransferase(ALT) levels were insignificantly higher in the study group than that in the control group.A day after surgery,the postoperative serum DBIL,TBIL,and ALT levels were lower than their preoperative levels in both groups,and of the two groups,the levels were lower in the study group.Although the preoperative serum adrenocorticotrophic(ACTH),cortisol(COR),epinephrine(A),and norepinephrine(NE) levels were higher in the study group than that in the control group,these differences were not significant(P > 0.05).The serum ACTH,COR,A,and NE levels in both groups decreased one day after surgery compared to the preoperative levels,but the inter-group difference was statistically insignificant.Similarly,(91.79 ±10.44) ng/mL,A,and NE levels were lower in the study group than in the control group.The incidence of complications was lower in the study group than in the control group.CONCLUSION LC combined with ERCP induces only a mild stress response;this procedure can decrease the risk of complications,improve liver function,and achieve and promote a faster recovery of gastrointestinal functions.