BACKGROUND At present,there are few studies on the risk factors for bile leakage after laparoscopic common bile duct exploration(LCBDE)for older patients with choledocholithiasis.AIM To identify the potential risk fac...BACKGROUND At present,there are few studies on the risk factors for bile leakage after laparoscopic common bile duct exploration(LCBDE)for older patients with choledocholithiasis.AIM To identify the potential risk factors for bile leakage after LCBDE in older patients.METHODS A retrospective,single-center observational analysis was performed on patients aged≥70 years with choledocholithiasis treated by LCBDE who were admitted to our center between January 2011 and August 2022.The included patients were divided into non-bile leakage and bile leakage groups.Risk factors were determined by analyzing the observation indicators.RESULTS Seventy older patients with choledocholithiasis who underwent LCBDE were included.Univariate analysis showed that positive culture of bile bacteria was a risk factor for bile leakage after LCBDE(P<0.05).We further analyzed the bile bacteria,and univariate analysis showed that Enterococcus faecalis(E.faecalis)(P<0.05)and Pseudomonas aeruginosa(P<0.05)were associated with an increased risk of postoperative bile leakage in older patients(P<0.05).Multivariate analysis showed that E. faecalis was an independent risk factor for postoperative bile leakage in older patients (P < 0.05). Theresults of antibiotic sensitivity analysis showed that E. faecalis had 100% susceptibility to penicillin, ampicillin,linezolid, vancomycin, and furantoin.CONCLUSIONE. faecalis-associated biliary tract infection is an independent risk factor for bile leakage after LCBDE in olderpatients with choledocholithiasis. We suggest coverage with antibiotics to which E. faecalis is sensitive.展开更多
BACKGROUND Bile leakage is a common complication following laparoscopic common bile duct exploration(LCBDE)with primary duct closure(PDC).Identifying and analyzing the risk factors associated with bile leakage is cruc...BACKGROUND Bile leakage is a common complication following laparoscopic common bile duct exploration(LCBDE)with primary duct closure(PDC).Identifying and analyzing the risk factors associated with bile leakage is crucial for improving surgical outcomes.AIM To explore the value analysis of common risk factors for bile leakage after LCBDE and PDC,with a focus on strict adherence to indications.METHODS Clinical data of 106 cases undergoing LCBDE+PDC in the Hepatobiliary and Pancreatic Surgery Department(Division 1)of Chuzhou First People’s Hospital from April 2019 to March 2024 were collected.Retrospective and multiple factor regression analysis were conducted on common risk factors for bile leakage.The change in surgical time was analyzed using the cumulative summation(CUSUM)method,and the minimum number of cases required to complete the learning curve for PDC was obtained based on the proposed fitting curve by identifying the CUSUM maximum value.RESULTS Multifactor logistic regression analysis showed that fibrinous inflammation and direct bilirubin/indirect bilirubin were significant independent high-risk factors for postoperative bile leakage(P<0.05).The time to drain removal and length of hospital stay in cases without bile leakage were significantly shorter than in cases with bile leakage(P<0.05),with statistical significance.The CUSUM method indicated that a minimum of 51 cases were required for the surgeon to complete the learning curve(P=0.023).CONCLUSION With a good assessment of duodenal papilla sphincter function,unobstructed bile-pancreatic duct convergence,exact stone clearance,and sufficient surgical experience to complete the learning curve,PDC remains the preferred method for bile duct closure and is worthy of clinical promotion.展开更多
BACKGROUND There remain controversies regarding the surgical treatment of extrahepatic bile duct stones(EHBDSs)in clinical practice.AIM To explore the curative effect of laparoscopic cholecystectomy(LC)plus common bil...BACKGROUND There remain controversies regarding the surgical treatment of extrahepatic bile duct stones(EHBDSs)in clinical practice.AIM To explore the curative effect of laparoscopic cholecystectomy(LC)plus common bile duct exploration(CBDE)for the surgical treatment of EHBDSs and to analyze the risk factors that affect postoperative stone recurrence.METHODS Eighty-two patients with EHBDSs admitted between March 2017 and March 2023 were selected.Among them,patients treated with open choledocholithotomy plus LC or open cholecystectomy(OC)were set as the control group(n=40),and those treated with LC plus CBDE served as the observation group(n=42).The surgical outcomes of the two groups were compared,the surgical complications and Gas-trointestinal Quality of Life Index(GIQLI)scores were counted,and the one-year prognostic recurrence was recorded.Independent factors for postoperative re-currence were determined using univariate and multivariate analyses.RESULTS The two groups were comparable in the stone residual rate(P>0.05).The ope-ration time(P<0.05),intraoperative bleeding(P<0.05),and total complication rate(P=0.005)were lower in the observation group than in the control group.The observation group exhibited a marked increase in the GIQLI score,which was higher than the control group(P<0.05).A lower one-year recurrence rate was determined in the observation group vs the control group(P=0.027).Sphincter of Oddi dysfunction[odds ratio(OR)=5.712,P=0.007]and the treatment scheme of open choledocholithotomy plus LC or OC(OR=6.771,P=0.008)were the independent risk factors for one-year recurrence in patients after surgery.CONCLUSION LC plus CBDE for patients with EHBDSs can reduce stone residuals,intraoperative bleeding,complications,and postoperative recurrence.展开更多
Surgical fraternity has not yet arrived at any consensus for adequate treatment of choledocholithiasis. Sequential treatment in the form of pre-operative endoscopic retrograde cholangio-pancreatography followed by lap...Surgical fraternity has not yet arrived at any consensus for adequate treatment of choledocholithiasis. Sequential treatment in the form of pre-operative endoscopic retrograde cholangio-pancreatography followed by laparoscopic cholecystectomy(LC) is considered as optimal treatment till date. With refinements in technique and expertise in field of minimal access surgery, many centres in the world have started offering one stage management of choledocholithiasis by LC with laparoscopic common bile duct exploration(LCBDE). Various modalities have been tried for entering into concurrent common bile duct(CBD) [transcystic(TC) vs transcholedochal(TD)], for confirming stone clearance(intraoperative cholangiogram vs choledochoscopy), and for closure of choledochotomy(T-tube vs biliary stent vs primary closure) during LCBDE. Both TC and TD approaches are safe and effective. TD stone extraction is involved with an increased risk of bile leaks and requires more expertise in intra-corporeal suturing and choledochoscopy. Choice depends on number of stones, size of stone, diameter of cystic duct and CBD. This review article was undertaken to evaluate the role of LCBDE for the management of choledocholithiasis.展开更多
BACKGROUND Laparoscopic cholecystectomy(LC)combined with laparoscopic common bile duct(CBD)exploration(LCBDE)is one of the main treatments for choledocholithiasis with CBD diameter of larger than 10 mm.However,for pat...BACKGROUND Laparoscopic cholecystectomy(LC)combined with laparoscopic common bile duct(CBD)exploration(LCBDE)is one of the main treatments for choledocholithiasis with CBD diameter of larger than 10 mm.However,for patients with small CBD(CBD diameter≤8 mm),endoscopic sphincterotomy remains the preferred treatment at present,but it also has some drawbacks associated with a series of complications,such as pancreatitis,hemorrhage,cholangitis,and duodenal perforation.To date,few studies have been reported that support the feasibility and safety of LCBDE for choledocholithiasis with small CBD.AIM To investigate the feasibility and safety of LCBDE for choledocholithiasis with small CBD.METHODS A total of 257 patients without acute cholangitis who underwent LC+LCBDE for cholecystolithiasis from January 2013 to December 2018 in one institution were reviewed.The clinical data were retrospectively collected and analyzed.According to whether the diameter of CBD was larger than 8 mm,257 patients were divided into large CBD group(n=146)and small CBD group(n=111).Propensity score matching(1:1)was performed to adjust for clinical differences.The demographics,intraoperative data,short-term outcomes,and long-term follow-up outcomes for the patients were recorded and compared.RESULTS In total,257 patients who underwent successful LC+LCBDE were enrolled in the study,146 had large CBD and 111 had small CBD.The median follow-up period was 39(14-86)mo.For small CBD patients,the median CBD diameter was 0.6 cm(0.2-2.0 cm),the mean operating time was 107.2±28.3 min,and the postoperative bile leak rate,rate of residual CBD stones(CBDS),CBDS recurrence rate,and CBD stenosis rate were 5.41%(6/111),3.60%(4/111),1.80%(2/111),and 0%(0/111),respectively;the mean postoperative hospital stay was 7.4±3.6 d.For large CBD patients,the median common bile duct diameter was 1.0 cm(0.3-3.0 cm),the mean operating time was 115.7±32.0 min,and the postoperative bile leak rate,rate of residual CBDS,CBDS recurrence rate,and CBD stenosis rate were 5.41%(9/146),1.37%(2/146),6.85%(10/146),and 0%(0/146),respectively;the mean postoperative hospital stay was 7.7±2.7 d.After propensity score matching,184 patients remained,and all preoperative covariates except diameter of CBD stones were balanced.Postoperative bile leak occurred in 11 patients overall(5.98%),and no difference was found between the small CBD group(4.35%,4/92)and the large CBD group(7.61%,7/92).The incidence of CBDS recurrence did not differ significantly between the small CBD group(2.17%,2/92)and the large CBD group(6.52%,6/92).CONCLUSION LC+LCBDE is safe and feasible for choledocholithiasis patients with small CBD and did not increase the postoperative bile leak rate compared with choledocholithiasis patients with large CBD.展开更多
BACKGROUND Laparoscopic cholecystectomy(LC)and laparoscopic common bile duct exploration(LCBDE)has been widely used for management of gallbladder and common bile duct(CBD)stones.Post-operative clip migration is a rare...BACKGROUND Laparoscopic cholecystectomy(LC)and laparoscopic common bile duct exploration(LCBDE)has been widely used for management of gallbladder and common bile duct(CBD)stones.Post-operative clip migration is a rare complication of laparoscopic biliary surgery,which can serve as a nidus for stone formation and cause recurrent cholangitis.CASE SUMMARY A 59-year-old female was admitted to hospital because of fever and acute right upper abdominal pain.She has a history of LC and had a LCBDE surgery 2 mo ago.Physical examination revealed tenderness in the upper quadrant of right abdomen.Computed tomography scan demonstrated a high-density shadow at the distal CBD,which was considered as migrated clips.The speculation was confirmed by endoscopic retrograde cholangiopancreatography examination,and two displaced Hem-o-lok clips were removed with a stone basket.No fever or abdominal pain presented after the operation.In addition to the case report,literature regarding surgical clip migration after laparoscopic biliary surgery was reviewed and discussed.CONCLUSION Incidence of postoperative clip migration may be reduced by using clips properly and correctly;however,new methods should be explored to occlude cystic duct and vessels.If a patient with a past history of LC or LCBDE presents with features of sepsis and recurrent upper quadrant pain,clip migration must be considered as one of the differential diagnosis.展开更多
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 und...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.展开更多
While endoscopic retrograde cholangiopancreatography(ERCP)remains the primary treatment modality for common bile duct stones(CBDS)or choledocho-lithiasis due to advancements in instruments,surgical intervention,known ...While endoscopic retrograde cholangiopancreatography(ERCP)remains the primary treatment modality for common bile duct stones(CBDS)or choledocho-lithiasis due to advancements in instruments,surgical intervention,known as common bile duct exploration(CBDE),is still necessary in cases of difficult CBDS,failed endoscopic treatment,or altered anatomy.Recent evidence also supports CBDE in patients requesting single-step cholecystectomy and bile duct stone removal with comparable outcomes.This review elucidates relevant clinical anatomy,selection indications,and outcomes to enhance surgical understanding.The selection between trans-cystic(TC)vs trans-choledochal(TD)approaches is described,along with stone removal techniques and ductal closure.Detailed surgical techniques and strategies for both the TC and TD approaches,including instrument selection,is also provided.Additionally,this review comprehensively addresses operation-specific complications such as bile leakage,stricture,and entrapment,and focuses on preventive measures and treatment strategies.This review aims to optimize the management of CBDS through laparoscopic CBDE,with the goal of improving patient outcomes and minimizing risks.展开更多
AIM:To evaluate the safety and effectiveness of twostage vs single-stage management for concomitant gallstones and common bile duct stones.METHODS:Four databases,including PubMed,Embase,the Cochrane Central Register o...AIM:To evaluate the safety and effectiveness of twostage vs single-stage management for concomitant gallstones and common bile duct stones.METHODS:Four databases,including PubMed,Embase,the Cochrane Central Register of Controlled Trials and the Science Citation Index up to September 2011,were searched to identify all randomized controlled trials(RCTs).Data were extracted from the studies by two independent reviewers.The primary outcomes were stone clearance from the common bile duct,postoperative morbidity and mortality.The secondary outcomes were conversion to other procedures,number of procedures per patient,length of hospital stay,total operative time,hospitalization charges,patient acceptance and quality of life scores.RESULTS:Seven eligible RCTs [five trials(n = 621) comparing preoperative endoscopic retrograde cholangiopancreatography(ERCP)/endoscopic sphincterotomy(EST) + laparoscopic cholecystectomy(LC) with LC + laparoscopic common bile duct exploration(LCBDE);two trials(n = 166) comparing postoperative ERCP/EST + LC with LC + LCBDE],composed of 787 patients in total,were included in the final analysis.The metaanalysis detected no statistically significant difference between the two groups in stone clearance from the common bile duct [risk ratios(RR) =-0.10,95% confidence intervals(CI):-0.24 to 0.04,P = 0.17],postoperative morbidity(RR = 0.79,95% CI:0.58 to 1.10,P = 0.16),mortality(RR = 2.19,95% CI:0.33 to 14.67,P = 0.42),conversion to other procedures(RR = 1.21,95% CI:0.54 to 2.70,P = 0.39),length of hospital stay(MD = 0.99,95% CI:-1.59 to 3.57,P = 0.45),total operative time(MD = 12.14,95% CI:-1.83 to 26.10,P = 0.09).Two-stage(LC + ERCP/EST) management clearly required more procedures per patient than single-stage(LC + LCBDE) management.CONCLUSION:Single-stage management is equivalent to two-stage management but requires fewer procedures.However,patient's condition,operator's expertise and local resources should be taken into account in making treatment decisions.展开更多
Up to 18% of patients submitted to cholecystectomy had concomitant common bile duct stones.To avoid serious complications,these stones should be removed.There is no consensus about the ideal management strategy for su...Up to 18% of patients submitted to cholecystectomy had concomitant common bile duct stones.To avoid serious complications,these stones should be removed.There is no consensus about the ideal management strategy for such patients.Traditionally,open surgery was offered but with the advent of endoscopic retrograde cholangiopancreatography(ERCP) and laparoscopic cholecystectomy(LC) minimally invasive approach had nearly replaced laparotomy because of its well-known advantages.Minimally invasive approach could be done in either twosession(preoperative ERCP followed by LC or LC followed by postoperative ERCP) or single-session(laparoscopic common bile duct exploration or LC with intraoperative ERCP).Most recent studies have found that both options are equivalent regarding safety and efficacy but the singlesession approach is associated with shorter hospital stay,fewer procedures per patient,and less cost.Consequently,single-session option should be offered to patients with cholecysto-choledocholithiaisis provided that local resources and expertise do exist.However,the management strategy should be tailored according to many variables,such as available resources,experience,patient characteristics,clinical presentations,and surgical pathology.展开更多
BACKGROUND Intraoperative and postoperative biliary injuries remain significant complications of laparoscopic common bile duct exploration(LCBDE).Indocyanine green(ICG)has been shown to significantly reduce injuries c...BACKGROUND Intraoperative and postoperative biliary injuries remain significant complications of laparoscopic common bile duct exploration(LCBDE).Indocyanine green(ICG)has been shown to significantly reduce injuries caused by intraoperative operational errors.We found that the J-tube can reduce postoperative strictures and injuries to the common bile duct.At this moment,we aim to analyze and compare the complications,efficacy,short-term outcomes,and feasibility of these two adjunctive tools for LCBDE.AIM To evaluate the efficacy of ICG fluorescence imaging In LCBDE and J-tube drainage for patients with common bile duct stones.METHODS We retrospectively collected the clinical case data of patients who were treated at the Hepatobiliary Surgery Department of the Third People’s Hospital of Nantong,affiliated with Nantong University,from January 2016 to January 2021 due to gallbladder stones with choledocholithiasis and who underwent LCBDE combined with a primary suture and either J-tube or T-tube drainage.The patients were divided into groups:Traditional white-light laparoscopy+T-tube group(WL+T-tube),traditional WL+J-tube group,fluorescent laparoscopy+T-tube group(ICG+T-tube)and fluorescent laparoscopy+J-tube group(ICG+J-tube).The preoperative and postoperative clinical case data,laboratory examination data,and intraoperative and postoperative complications(including postoperative bile leakage,electrolyte disturbances,biliary peritonitis,and postoperative infections)and other relevant indicators were compared.RESULTS A total of 198 patients(112 males and 86 females)were included in the study,with 74 patients in the WL+T-tube,47 in the WL+J-tube,42 in the ICG+T-tube,and 35 in the ICG+J-tube.Compared with the other groups,the ICG+J had significantly shorter operation time(114 minutes,P=0.001),less blood loss(42 mL,P=0.02),shorter postoperative hospital stays(7 days,P=0.038),and lower surgical costs(China yuan 30178,P=0.001).Furthermore,patients were subdivided into two groups based on whether a T-tube or J-tube was placed during the surgery.By the third postoperative day,the aspartate transaminase,glutamic pyruvic transaminase,total bilirubin,and direct bilirubin levels were lower in the J-tube group than in the T-tube group(P<0.001).At last,follow-up observations showed that the incidence of biliary strictures at three months postoperatively was significantly lower in the J-tube group than in the T-tube group(P=0.002).CONCLUSION ICG fluorescence imaging in laparoscopic cholecystectomy with common bile duct exploration and J-tube drainage facilitates rapid identification of biliary anatomy and variations,reducing intraoperative bile duct injury,blood loss,surgery duration,and postoperative bile duct stenosis rates,supporting its clinical adoption.展开更多
BACKGROUND Currently,endoscopic retrograde cholangiopancreatography(ERCP)plus laparoscopic cholecystectomy(LC)is the main treatment for cholecystolithiasis combined with choledocholithiasis.However,the treatment is un...BACKGROUND Currently,endoscopic retrograde cholangiopancreatography(ERCP)plus laparoscopic cholecystectomy(LC)is the main treatment for cholecystolithiasis combined with choledocholithiasis.However,the treatment is unsatisfactory,and the development of better therapies is needed.AIM To determine the clinical efficacy of LC plus cholangioscopy for cholecystolithiasis combined with choledocholithiasis.METHODS Patients(n=243)with cholecystolithiasis and choledocholithiasis admitted to The Affiliated Haixia Hospital of Huaqiao University(910th Hospital of Joint Logistic Support Force)between January 2019 and December 2023 were included in the study;111 patients(control group)underwent ERCP+LC and 132 patients(observation group)underwent LC+laparoscopic common bile duct exploration(LCBDE).Surgical success rates,residual stone rates,complications(pancreatitis,hyperamylasemia,biliary tract infection,and bile leakage),surgical indicators[intraoperative blood loss(IBL)and operation time(OT)],recovery indices(postoperative exhaust/defecation time and hospital stay),and serum inflammatory markers[C-reactive protein(CRP)],tumor necrosis factor-α(TNF-α),and interleukin-6(IL-6)were compared.RESULTS No significant differences in surgical success rates and residual stone rates were detected between the observation and control groups.However,the complication rate,IBL,OT,postoperative exhaust/defecation time,and hospital stays were significantly reduced in the observation group compared with the control group.Furthermore,CRP,TNF-α,and IL-6 Levels after treatment were reduced in the observation group compared with the levels in the control group.CONCLUSION These results indicate that LC+LCBDE is safer than ERCP+LC for the treatment of cholecystolithiasis combined with choledocholithiasis.The surgical risks and postoperative complications were lower in the observation group compared with the control group.Thus,patients may recover quickly with less inflammation after LCBDE.展开更多
Background and aims:Laparoscopic common bile duct exploration(LCBDE)is considered a safe and effective method for the removal of bile duct stones.However,the choice of primary duct closure(PDC)or T-tube drainage(TTD)t...Background and aims:Laparoscopic common bile duct exploration(LCBDE)is considered a safe and effective method for the removal of bile duct stones.However,the choice of primary duct closure(PDC)or T-tube drainage(TTD)technique after LCBDE is still controversial.This study aimed to compare the safety and effectiveness of PDC and TTD after LCBDE.Methods:Studies published before May 1,2021 in Pub Med,Web of Science,and Cochrane Library databases were searched to screen out randomized controlled trials(RCTs)and cohort studies to compare PDC with TTD.Meta-analyses of fixed effect and random effect models were performed using Rev Man 5.3.Results:A total of 1865 patients were enrolled in six RCTs and ten cohort studies.Regarding RCTs,the PDC group was significantly better than the TTD group in terms of operation time,total postoperative complications,postoperative hospital stay,and hospitalization expenses(all P<0.05).Based on cohort studies of the subgroup,the PDC group had shorter operation time,shorter postoperative hospital stay,less intraoperative blood loss,and limited total postoperative complications.Statistically,there were no significant differences in bile leakage,retained stones,stone recurrence,bile duct stricture,postoperative pancreatitis,other complications,or postoperative exhaust time between the TTD and PDC groups.Conclusions:Based on the available evidence,compared with TTD,PDC is safe and effective,and can be used as the first choice after transductal LCBDE in patients with choledocholithiasis.展开更多
基金Supported by the Ke Qiao Science and Technology Plan Projects,No.2022KZ70.
文摘BACKGROUND At present,there are few studies on the risk factors for bile leakage after laparoscopic common bile duct exploration(LCBDE)for older patients with choledocholithiasis.AIM To identify the potential risk factors for bile leakage after LCBDE in older patients.METHODS A retrospective,single-center observational analysis was performed on patients aged≥70 years with choledocholithiasis treated by LCBDE who were admitted to our center between January 2011 and August 2022.The included patients were divided into non-bile leakage and bile leakage groups.Risk factors were determined by analyzing the observation indicators.RESULTS Seventy older patients with choledocholithiasis who underwent LCBDE were included.Univariate analysis showed that positive culture of bile bacteria was a risk factor for bile leakage after LCBDE(P<0.05).We further analyzed the bile bacteria,and univariate analysis showed that Enterococcus faecalis(E.faecalis)(P<0.05)and Pseudomonas aeruginosa(P<0.05)were associated with an increased risk of postoperative bile leakage in older patients(P<0.05).Multivariate analysis showed that E. faecalis was an independent risk factor for postoperative bile leakage in older patients (P < 0.05). Theresults of antibiotic sensitivity analysis showed that E. faecalis had 100% susceptibility to penicillin, ampicillin,linezolid, vancomycin, and furantoin.CONCLUSIONE. faecalis-associated biliary tract infection is an independent risk factor for bile leakage after LCBDE in olderpatients with choledocholithiasis. We suggest coverage with antibiotics to which E. faecalis is sensitive.
基金Supported by the Wannan Medical College Teaching Hospital Special Application for Scientific Research,No.WK2023JXYY036the Anhui Provincial Translational Clinical Medical Research Special Application,No.202204295107020062.
文摘BACKGROUND Bile leakage is a common complication following laparoscopic common bile duct exploration(LCBDE)with primary duct closure(PDC).Identifying and analyzing the risk factors associated with bile leakage is crucial for improving surgical outcomes.AIM To explore the value analysis of common risk factors for bile leakage after LCBDE and PDC,with a focus on strict adherence to indications.METHODS Clinical data of 106 cases undergoing LCBDE+PDC in the Hepatobiliary and Pancreatic Surgery Department(Division 1)of Chuzhou First People’s Hospital from April 2019 to March 2024 were collected.Retrospective and multiple factor regression analysis were conducted on common risk factors for bile leakage.The change in surgical time was analyzed using the cumulative summation(CUSUM)method,and the minimum number of cases required to complete the learning curve for PDC was obtained based on the proposed fitting curve by identifying the CUSUM maximum value.RESULTS Multifactor logistic regression analysis showed that fibrinous inflammation and direct bilirubin/indirect bilirubin were significant independent high-risk factors for postoperative bile leakage(P<0.05).The time to drain removal and length of hospital stay in cases without bile leakage were significantly shorter than in cases with bile leakage(P<0.05),with statistical significance.The CUSUM method indicated that a minimum of 51 cases were required for the surgeon to complete the learning curve(P=0.023).CONCLUSION With a good assessment of duodenal papilla sphincter function,unobstructed bile-pancreatic duct convergence,exact stone clearance,and sufficient surgical experience to complete the learning curve,PDC remains the preferred method for bile duct closure and is worthy of clinical promotion.
文摘BACKGROUND There remain controversies regarding the surgical treatment of extrahepatic bile duct stones(EHBDSs)in clinical practice.AIM To explore the curative effect of laparoscopic cholecystectomy(LC)plus common bile duct exploration(CBDE)for the surgical treatment of EHBDSs and to analyze the risk factors that affect postoperative stone recurrence.METHODS Eighty-two patients with EHBDSs admitted between March 2017 and March 2023 were selected.Among them,patients treated with open choledocholithotomy plus LC or open cholecystectomy(OC)were set as the control group(n=40),and those treated with LC plus CBDE served as the observation group(n=42).The surgical outcomes of the two groups were compared,the surgical complications and Gas-trointestinal Quality of Life Index(GIQLI)scores were counted,and the one-year prognostic recurrence was recorded.Independent factors for postoperative re-currence were determined using univariate and multivariate analyses.RESULTS The two groups were comparable in the stone residual rate(P>0.05).The ope-ration time(P<0.05),intraoperative bleeding(P<0.05),and total complication rate(P=0.005)were lower in the observation group than in the control group.The observation group exhibited a marked increase in the GIQLI score,which was higher than the control group(P<0.05).A lower one-year recurrence rate was determined in the observation group vs the control group(P=0.027).Sphincter of Oddi dysfunction[odds ratio(OR)=5.712,P=0.007]and the treatment scheme of open choledocholithotomy plus LC or OC(OR=6.771,P=0.008)were the independent risk factors for one-year recurrence in patients after surgery.CONCLUSION LC plus CBDE for patients with EHBDSs can reduce stone residuals,intraoperative bleeding,complications,and postoperative recurrence.
文摘Surgical fraternity has not yet arrived at any consensus for adequate treatment of choledocholithiasis. Sequential treatment in the form of pre-operative endoscopic retrograde cholangio-pancreatography followed by laparoscopic cholecystectomy(LC) is considered as optimal treatment till date. With refinements in technique and expertise in field of minimal access surgery, many centres in the world have started offering one stage management of choledocholithiasis by LC with laparoscopic common bile duct exploration(LCBDE). Various modalities have been tried for entering into concurrent common bile duct(CBD) [transcystic(TC) vs transcholedochal(TD)], for confirming stone clearance(intraoperative cholangiogram vs choledochoscopy), and for closure of choledochotomy(T-tube vs biliary stent vs primary closure) during LCBDE. Both TC and TD approaches are safe and effective. TD stone extraction is involved with an increased risk of bile leaks and requires more expertise in intra-corporeal suturing and choledochoscopy. Choice depends on number of stones, size of stone, diameter of cystic duct and CBD. This review article was undertaken to evaluate the role of LCBDE for the management of choledocholithiasis.
文摘BACKGROUND Laparoscopic cholecystectomy(LC)combined with laparoscopic common bile duct(CBD)exploration(LCBDE)is one of the main treatments for choledocholithiasis with CBD diameter of larger than 10 mm.However,for patients with small CBD(CBD diameter≤8 mm),endoscopic sphincterotomy remains the preferred treatment at present,but it also has some drawbacks associated with a series of complications,such as pancreatitis,hemorrhage,cholangitis,and duodenal perforation.To date,few studies have been reported that support the feasibility and safety of LCBDE for choledocholithiasis with small CBD.AIM To investigate the feasibility and safety of LCBDE for choledocholithiasis with small CBD.METHODS A total of 257 patients without acute cholangitis who underwent LC+LCBDE for cholecystolithiasis from January 2013 to December 2018 in one institution were reviewed.The clinical data were retrospectively collected and analyzed.According to whether the diameter of CBD was larger than 8 mm,257 patients were divided into large CBD group(n=146)and small CBD group(n=111).Propensity score matching(1:1)was performed to adjust for clinical differences.The demographics,intraoperative data,short-term outcomes,and long-term follow-up outcomes for the patients were recorded and compared.RESULTS In total,257 patients who underwent successful LC+LCBDE were enrolled in the study,146 had large CBD and 111 had small CBD.The median follow-up period was 39(14-86)mo.For small CBD patients,the median CBD diameter was 0.6 cm(0.2-2.0 cm),the mean operating time was 107.2±28.3 min,and the postoperative bile leak rate,rate of residual CBD stones(CBDS),CBDS recurrence rate,and CBD stenosis rate were 5.41%(6/111),3.60%(4/111),1.80%(2/111),and 0%(0/111),respectively;the mean postoperative hospital stay was 7.4±3.6 d.For large CBD patients,the median common bile duct diameter was 1.0 cm(0.3-3.0 cm),the mean operating time was 115.7±32.0 min,and the postoperative bile leak rate,rate of residual CBDS,CBDS recurrence rate,and CBD stenosis rate were 5.41%(9/146),1.37%(2/146),6.85%(10/146),and 0%(0/146),respectively;the mean postoperative hospital stay was 7.7±2.7 d.After propensity score matching,184 patients remained,and all preoperative covariates except diameter of CBD stones were balanced.Postoperative bile leak occurred in 11 patients overall(5.98%),and no difference was found between the small CBD group(4.35%,4/92)and the large CBD group(7.61%,7/92).The incidence of CBDS recurrence did not differ significantly between the small CBD group(2.17%,2/92)and the large CBD group(6.52%,6/92).CONCLUSION LC+LCBDE is safe and feasible for choledocholithiasis patients with small CBD and did not increase the postoperative bile leak rate compared with choledocholithiasis patients with large CBD.
基金Medical and Health Technology Plan of Zhejiang Province,No.2019RC179.
文摘BACKGROUND Laparoscopic cholecystectomy(LC)and laparoscopic common bile duct exploration(LCBDE)has been widely used for management of gallbladder and common bile duct(CBD)stones.Post-operative clip migration is a rare complication of laparoscopic biliary surgery,which can serve as a nidus for stone formation and cause recurrent cholangitis.CASE SUMMARY A 59-year-old female was admitted to hospital because of fever and acute right upper abdominal pain.She has a history of LC and had a LCBDE surgery 2 mo ago.Physical examination revealed tenderness in the upper quadrant of right abdomen.Computed tomography scan demonstrated a high-density shadow at the distal CBD,which was considered as migrated clips.The speculation was confirmed by endoscopic retrograde cholangiopancreatography examination,and two displaced Hem-o-lok clips were removed with a stone basket.No fever or abdominal pain presented after the operation.In addition to the case report,literature regarding surgical clip migration after laparoscopic biliary surgery was reviewed and discussed.CONCLUSION Incidence of postoperative clip migration may be reduced by using clips properly and correctly;however,new methods should be explored to occlude cystic duct and vessels.If a patient with a past history of LC or LCBDE presents with features of sepsis and recurrent upper quadrant pain,clip migration must be considered as one of the differential diagnosis.
文摘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.
文摘While endoscopic retrograde cholangiopancreatography(ERCP)remains the primary treatment modality for common bile duct stones(CBDS)or choledocho-lithiasis due to advancements in instruments,surgical intervention,known as common bile duct exploration(CBDE),is still necessary in cases of difficult CBDS,failed endoscopic treatment,or altered anatomy.Recent evidence also supports CBDE in patients requesting single-step cholecystectomy and bile duct stone removal with comparable outcomes.This review elucidates relevant clinical anatomy,selection indications,and outcomes to enhance surgical understanding.The selection between trans-cystic(TC)vs trans-choledochal(TD)approaches is described,along with stone removal techniques and ductal closure.Detailed surgical techniques and strategies for both the TC and TD approaches,including instrument selection,is also provided.Additionally,this review comprehensively addresses operation-specific complications such as bile leakage,stricture,and entrapment,and focuses on preventive measures and treatment strategies.This review aims to optimize the management of CBDS through laparoscopic CBDE,with the goal of improving patient outcomes and minimizing risks.
文摘AIM:To evaluate the safety and effectiveness of twostage vs single-stage management for concomitant gallstones and common bile duct stones.METHODS:Four databases,including PubMed,Embase,the Cochrane Central Register of Controlled Trials and the Science Citation Index up to September 2011,were searched to identify all randomized controlled trials(RCTs).Data were extracted from the studies by two independent reviewers.The primary outcomes were stone clearance from the common bile duct,postoperative morbidity and mortality.The secondary outcomes were conversion to other procedures,number of procedures per patient,length of hospital stay,total operative time,hospitalization charges,patient acceptance and quality of life scores.RESULTS:Seven eligible RCTs [five trials(n = 621) comparing preoperative endoscopic retrograde cholangiopancreatography(ERCP)/endoscopic sphincterotomy(EST) + laparoscopic cholecystectomy(LC) with LC + laparoscopic common bile duct exploration(LCBDE);two trials(n = 166) comparing postoperative ERCP/EST + LC with LC + LCBDE],composed of 787 patients in total,were included in the final analysis.The metaanalysis detected no statistically significant difference between the two groups in stone clearance from the common bile duct [risk ratios(RR) =-0.10,95% confidence intervals(CI):-0.24 to 0.04,P = 0.17],postoperative morbidity(RR = 0.79,95% CI:0.58 to 1.10,P = 0.16),mortality(RR = 2.19,95% CI:0.33 to 14.67,P = 0.42),conversion to other procedures(RR = 1.21,95% CI:0.54 to 2.70,P = 0.39),length of hospital stay(MD = 0.99,95% CI:-1.59 to 3.57,P = 0.45),total operative time(MD = 12.14,95% CI:-1.83 to 26.10,P = 0.09).Two-stage(LC + ERCP/EST) management clearly required more procedures per patient than single-stage(LC + LCBDE) management.CONCLUSION:Single-stage management is equivalent to two-stage management but requires fewer procedures.However,patient's condition,operator's expertise and local resources should be taken into account in making treatment decisions.
文摘Up to 18% of patients submitted to cholecystectomy had concomitant common bile duct stones.To avoid serious complications,these stones should be removed.There is no consensus about the ideal management strategy for such patients.Traditionally,open surgery was offered but with the advent of endoscopic retrograde cholangiopancreatography(ERCP) and laparoscopic cholecystectomy(LC) minimally invasive approach had nearly replaced laparotomy because of its well-known advantages.Minimally invasive approach could be done in either twosession(preoperative ERCP followed by LC or LC followed by postoperative ERCP) or single-session(laparoscopic common bile duct exploration or LC with intraoperative ERCP).Most recent studies have found that both options are equivalent regarding safety and efficacy but the singlesession approach is associated with shorter hospital stay,fewer procedures per patient,and less cost.Consequently,single-session option should be offered to patients with cholecysto-choledocholithiaisis provided that local resources and expertise do exist.However,the management strategy should be tailored according to many variables,such as available resources,experience,patient characteristics,clinical presentations,and surgical pathology.
文摘BACKGROUND Intraoperative and postoperative biliary injuries remain significant complications of laparoscopic common bile duct exploration(LCBDE).Indocyanine green(ICG)has been shown to significantly reduce injuries caused by intraoperative operational errors.We found that the J-tube can reduce postoperative strictures and injuries to the common bile duct.At this moment,we aim to analyze and compare the complications,efficacy,short-term outcomes,and feasibility of these two adjunctive tools for LCBDE.AIM To evaluate the efficacy of ICG fluorescence imaging In LCBDE and J-tube drainage for patients with common bile duct stones.METHODS We retrospectively collected the clinical case data of patients who were treated at the Hepatobiliary Surgery Department of the Third People’s Hospital of Nantong,affiliated with Nantong University,from January 2016 to January 2021 due to gallbladder stones with choledocholithiasis and who underwent LCBDE combined with a primary suture and either J-tube or T-tube drainage.The patients were divided into groups:Traditional white-light laparoscopy+T-tube group(WL+T-tube),traditional WL+J-tube group,fluorescent laparoscopy+T-tube group(ICG+T-tube)and fluorescent laparoscopy+J-tube group(ICG+J-tube).The preoperative and postoperative clinical case data,laboratory examination data,and intraoperative and postoperative complications(including postoperative bile leakage,electrolyte disturbances,biliary peritonitis,and postoperative infections)and other relevant indicators were compared.RESULTS A total of 198 patients(112 males and 86 females)were included in the study,with 74 patients in the WL+T-tube,47 in the WL+J-tube,42 in the ICG+T-tube,and 35 in the ICG+J-tube.Compared with the other groups,the ICG+J had significantly shorter operation time(114 minutes,P=0.001),less blood loss(42 mL,P=0.02),shorter postoperative hospital stays(7 days,P=0.038),and lower surgical costs(China yuan 30178,P=0.001).Furthermore,patients were subdivided into two groups based on whether a T-tube or J-tube was placed during the surgery.By the third postoperative day,the aspartate transaminase,glutamic pyruvic transaminase,total bilirubin,and direct bilirubin levels were lower in the J-tube group than in the T-tube group(P<0.001).At last,follow-up observations showed that the incidence of biliary strictures at three months postoperatively was significantly lower in the J-tube group than in the T-tube group(P=0.002).CONCLUSION ICG fluorescence imaging in laparoscopic cholecystectomy with common bile duct exploration and J-tube drainage facilitates rapid identification of biliary anatomy and variations,reducing intraoperative bile duct injury,blood loss,surgery duration,and postoperative bile duct stenosis rates,supporting its clinical adoption.
文摘BACKGROUND Currently,endoscopic retrograde cholangiopancreatography(ERCP)plus laparoscopic cholecystectomy(LC)is the main treatment for cholecystolithiasis combined with choledocholithiasis.However,the treatment is unsatisfactory,and the development of better therapies is needed.AIM To determine the clinical efficacy of LC plus cholangioscopy for cholecystolithiasis combined with choledocholithiasis.METHODS Patients(n=243)with cholecystolithiasis and choledocholithiasis admitted to The Affiliated Haixia Hospital of Huaqiao University(910th Hospital of Joint Logistic Support Force)between January 2019 and December 2023 were included in the study;111 patients(control group)underwent ERCP+LC and 132 patients(observation group)underwent LC+laparoscopic common bile duct exploration(LCBDE).Surgical success rates,residual stone rates,complications(pancreatitis,hyperamylasemia,biliary tract infection,and bile leakage),surgical indicators[intraoperative blood loss(IBL)and operation time(OT)],recovery indices(postoperative exhaust/defecation time and hospital stay),and serum inflammatory markers[C-reactive protein(CRP)],tumor necrosis factor-α(TNF-α),and interleukin-6(IL-6)were compared.RESULTS No significant differences in surgical success rates and residual stone rates were detected between the observation and control groups.However,the complication rate,IBL,OT,postoperative exhaust/defecation time,and hospital stays were significantly reduced in the observation group compared with the control group.Furthermore,CRP,TNF-α,and IL-6 Levels after treatment were reduced in the observation group compared with the levels in the control group.CONCLUSION These results indicate that LC+LCBDE is safer than ERCP+LC for the treatment of cholecystolithiasis combined with choledocholithiasis.The surgical risks and postoperative complications were lower in the observation group compared with the control group.Thus,patients may recover quickly with less inflammation after LCBDE.
基金supported by the National Natural Science Foundation of China(Nos.81972262,81972255,81772597,81801999,and 81702904)the Guangdong Basic and Applied Basic Research Foundation(Nos.2020A1515010117 and2018A030313645)+4 种基金the Fundamental Research Funds for the Central Universities(No.18ykpy22)the Key Laboratory of Malignant Tumor Molecular Mechanism and Translational Medicine of Guangzhou Bureau of Science and Information Technology(No.[2013]163)the Key Laboratory of Malignant Tumor Gene Regulation and Target Therapy of Guangdong Higher Education Institutes(No.KLB09001)the Guangdong Science and Technology Department(Nos.2015B050501004and 2017B030314026)the Shangrao Science and Technology Department(No.2020D001),China。
文摘Background and aims:Laparoscopic common bile duct exploration(LCBDE)is considered a safe and effective method for the removal of bile duct stones.However,the choice of primary duct closure(PDC)or T-tube drainage(TTD)technique after LCBDE is still controversial.This study aimed to compare the safety and effectiveness of PDC and TTD after LCBDE.Methods:Studies published before May 1,2021 in Pub Med,Web of Science,and Cochrane Library databases were searched to screen out randomized controlled trials(RCTs)and cohort studies to compare PDC with TTD.Meta-analyses of fixed effect and random effect models were performed using Rev Man 5.3.Results:A total of 1865 patients were enrolled in six RCTs and ten cohort studies.Regarding RCTs,the PDC group was significantly better than the TTD group in terms of operation time,total postoperative complications,postoperative hospital stay,and hospitalization expenses(all P<0.05).Based on cohort studies of the subgroup,the PDC group had shorter operation time,shorter postoperative hospital stay,less intraoperative blood loss,and limited total postoperative complications.Statistically,there were no significant differences in bile leakage,retained stones,stone recurrence,bile duct stricture,postoperative pancreatitis,other complications,or postoperative exhaust time between the TTD and PDC groups.Conclusions:Based on the available evidence,compared with TTD,PDC is safe and effective,and can be used as the first choice after transductal LCBDE in patients with choledocholithiasis.
