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Cianci P, Restini E. Management of cholelithiasis with choledocholithiasis: Endoscopic and surgical approaches. World J Gastroenterol 2021; 27:4536-4554. [PMID: 34366622 PMCID: PMC8326257 DOI: 10.3748/wjg.v27.i28.4536] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 04/02/2021] [Accepted: 06/25/2021] [Indexed: 02/06/2023] Open
Abstract
Gallstone disease and complications from gallstones are a common clinical problem. The clinical presentation ranges between being asymptomatic and recurrent attacks of biliary pain requiring elective or emergency treatment. Bile duct stones are a frequent condition associated with cholelithiasis. Amidst the total cholecystectomies performed every year for cholelithiasis, the presence of bile duct stones is 5%-15%; another small percentage of these will develop common bile duct stones after intervention. To avoid serious complications that can occur in choledocholithiasis, these stones should be removed. Unfortunately, there is no consensus on the ideal management strategy to perform such. For a long time, a direct open surgical approach to the bile duct was the only unique approach. With the advent of advanced endoscopic, radiologic, and minimally invasive surgical techniques, however, therapeutic choices have increased in number, and the management of this pathological situation has become multidisciplinary. To date, there is agreement on preoperative management and the need to treat cholelithiasis with choledocholithiasis, but a debate still exists on how to cure the two diseases at the same time. In the era of laparoscopy and mini-invasiveness, we can say that therapeutic approaches can be performed in two sessions or in one session. Comparison of these two approaches showed equivalent success rates, postoperative morbidity, stone clearance, mortality, conversion to other procedures, total surgery time, and failure rate, but the one-session treatment is characterized by a shorter hospital stay, and more cost benefits. The aim of this review article is to provide the reader with a general summary of gallbladder stone disease in association with the presence of common bile duct stones by discussing their epidemiology, clinical and diagnostic aspects, and possible treatments and their advantages and limitations.
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Affiliation(s)
- Pasquale Cianci
- Department of Surgery and Traumatology, Hospital Lorenzo Bonomo, Andria 76123, Italy
| | - Enrico Restini
- Department of Surgery and Traumatology, Hospital Lorenzo Bonomo, Andria 76123, Italy
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Helton WS, Ayloo S. Technical Aspects of Bile Duct Evaluation and Exploration: An Update. Surg Clin North Am 2019; 99:259-282. [PMID: 30846034 DOI: 10.1016/j.suc.2018.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Consensus guidelines recommend patients with symptomatic cholelithiasis and suspected choledocholithiasis have common bile duct exploration (CBDE) at the time of cholecystectomy to prevent downstream problems. Despite superiority of single-stage cholecystectomy with CBDE, 2-stage precholecystectomy/postcholecystectomy with endoscopic clearance of the duct is commonly practiced. This is related to inadequate training in minimally invasive techniques, lack of technical support for efficient and safe CBDE, and surgeons' inexperience with complex biliary pathologic condition. This article provides a framework for evaluating and treating patients with CBD pathologic condition with an emphasis on technical aspects of CBDE and preoperative planning and preparation.
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Affiliation(s)
| | - Subhashini Ayloo
- Rutgers, New Jersey Medical School, 185 South Orange Avenue, MSB G586, Newark, NJ 07103, USA.
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Rehman SFU, Ballance L, Rate A. Selective Antegrade Biliary Stenting Aids Emergency Laparoscopic Cholecystectomy. J Laparoendosc Adv Surg Tech A 2018; 28:1495-1502. [PMID: 29993317 DOI: 10.1089/lap.2018.0300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background: Symptomatic gall stone disease requires early emergency treatment to prevent complications. This early treatment is often delayed due to difficulty in the diagnosis and management of concomitant choledocholithiasis. Intervention with preoperative endoscopic retrograde cholangiopancreatography (ERCP) is associated with complications and known to be unnecessary in most cases. We follow a strategy of providing early cholecystectomy with selective utility of antegrade stent in cases of choledocholithiasis. Our main aim is to present our technique and results. Method: We conducted a 3-year (January 2014 to January 2017) review of a prospectively maintained database of our practice of performing routine intraoperative cholangiogram (IOC) during laparoscopic cholecystectomy (LC) and when choledocholithiasis is encountered on IOC; a transcystic antegrade biliary stent is inserted to decompress the common bile ducts (CBD) and facilitate postoperative ERCP at later date. Results: Of the 411 cholecystectomies performed, 77.3% were females with mean age of 48 years. Seventy-four patients were found to have CBD stones (CBDS) on IOC. Antegrade stents were successfully deployed in 69 cases. Even though Antegrade stents were done more frequently in emergency admissions (P = .001); this did not increase the length of hospital stay (LOHS) (P = .752) or the rate of complications (P = .171). However, doing a preoperative ERCP significantly increased LOHS (P = .001), and 67% of these needed two or more ERCP for complete clearance of CBD and had more complications. Nine (15.2%) out of 59 patients with pancreatitis had CBDS on IOC and were successfully managed with antegrade stent. Conclusion: This strategy can be followed by general surgeons, enabling them to perform LC in the presence of choledocholithiasis during acute admissions including pancreatitis. It does not require any specialist skills in CBD exploration and also eliminates unnecessary preoperative ERCP and avoids its potential complications.
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Affiliation(s)
- Sheik Fazal Ur Rehman
- Department of General Surgery, Royal Oldham Hospital, Oldham, Manchester, United Kingdom
| | - Laura Ballance
- Department of General Surgery, Royal Oldham Hospital, Oldham, Manchester, United Kingdom
| | - Anthony Rate
- Department of General Surgery, Royal Oldham Hospital, Oldham, Manchester, United Kingdom
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Dietrich A, Alvarez F, Resio N, Mazza O, de Santibañes E, Pekolj J, Clariá RS, de Santibañes M. Laparoscopic management of common bile duct stones: transpapillary stenting or external biliary drainage? JSLS 2016; 18:JSLS-D-13-00277. [PMID: 25489219 PMCID: PMC4254483 DOI: 10.4293/jsls.2014.00277] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND To date, the management of common bile duct stones (CBDs) is still controversial. If laparoscopic exploration is performed and biliary decompression is needed after stone removal, the placement of a laparoscopic transpapillary stent shows promising results in avoiding T-tube-related complications. METHODS Between January 2007 and May 2012, a series of 48 patients who underwent biliary decompression after laparoscopic common bile duct exploration (LCBDE) to treat choledocholithiasis was retrospectively analyzed. The results in patients with transpapillary stent placement (TS=35) were compared with those who had an external biliary drainage (EBD=13). RESULTS LCBDE and TS placement was achieved either by a choledochotomy or through the cystic duct. There was no mortality in our series. Patients with an external biliary drainage (EBD) had more surgery-related complications (P<.0001) and a longer hospital stay (P=.03). Postoperative ERCP to remove the TS was successful in all cases. CONCLUSION Laparoscopic TS is a safe method in the treatment of selected patients with CBD stones that can be achieved without having to perform a choledochotomy. Because of the lower morbidity and the shorter hospital stay compared with EBD, it should be considered as a first approach whenever biliary decompression is needed after LCBDE.
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Affiliation(s)
- Agustin Dietrich
- Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Fernando Alvarez
- Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Nicolas Resio
- Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Oscar Mazza
- Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Eduardo de Santibañes
- Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Juan Pekolj
- Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Rodrigo Sanchez Clariá
- Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Martin de Santibañes
- Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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ElGeidie AA. Single-session minimally invasive management of common bile duct stones. World J Gastroenterol 2014; 20:15144-15152. [PMID: 25386063 PMCID: PMC4223248 DOI: 10.3748/wjg.v20.i41.15144] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Revised: 03/06/2014] [Accepted: 06/26/2014] [Indexed: 02/06/2023] Open
Abstract
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 two-session (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 single-session 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.
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Lyon M, Menon S, Jain A, Kumar H. Use of biliary stent in laparoscopic common bile duct exploration. Surg Endosc 2014; 29:1094-8. [PMID: 25249145 DOI: 10.1007/s00464-014-3797-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Accepted: 08/04/2014] [Indexed: 12/16/2022]
Abstract
INTRODUCTION It is well supported in the literature that laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis has equal efficacy when compared to ERCP followed by laparoscopic cholecystectomy. Decompression after supra-duodenal choledochotomy is common practice as it reduced the risk of bile leaks. We conducted a prospective non-randomized study to compare outcomes and length of stay in patients undergoing biliary stent insertion versus T-tube drainage following LCBDE via choledochotomy. METHODS AND PROCEDURES The study involved 116 patients with choledocholithiasis who underwent LCBDE and decompression of the biliary system by either ante-grade biliary stent or T-tube insertion. A 7 French straight/duodenal curve biliary Diagmed™ stent (9-11 cm) was placed in 82 patients (Biliary Stent Group). T-tube insertion was used for 34 patients (T-tube group). The length of hospital stay and complications for the selected patients were recorded. All trans-cystic common bile duct explorations were excluded from the study. RESULTS The mean hospital stay for patients who underwent ante-grade biliary stent or T-tube insertion after LBCDE were 1 and 3.4 days, respectively. This is a statistically significant result with a p value of less than 0.001. Of the T-tube group, two patients required laparoscopic washout due to bile leaks, one had ongoing biliary stasis and one reported ongoing pain whilst the T-tube was in situ. A complication rate of 11.2%, this was a significant finding. There were no complications or concerns reported for the Biliary Stent Group. CONCLUSION Our results show that there is a significant reduction in length of hospital stay and morbidity for patients that have ante-grade biliary stent decompression of the CBD post laparoscopic choledochotomy when compared T-tube drainage. This implies that ante-grade biliary stent insertion is likely to reduce costs and increase overall patient satisfaction. We support the use of ante-grade biliary stent insertion during LCBDE when primary closure is not preferred.
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Affiliation(s)
- Matthew Lyon
- Department of Surgery Darling Downs Health Service, Queensland Health, Toowoomba, QLD, Australia,
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A randomized trial comparing the use of endobiliary stent and T-tube for biliary decompression after laparoscopic common bile duct exploration. Surg Laparosc Endosc Percutan Tech 2012; 22:345-8. [PMID: 22874685 DOI: 10.1097/sle.0b013e31825b297d] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE To compare the use of a biliary stent with T-tube for biliary decompression after laparoscopic common bile duct (CBD) exploration. METHODS Between September 2004 and March 2008, 60 patients undergoing laparoscopic CBD exploration for CBD stones were randomized to choledochotomy closure over either a biliary stent or a T-tube after CBD clearance. Patients at high risk for surgery and unremitting cholangitis requiring preoperative endoscopic biliary drainage were excluded. RESULTS There were 29 and 31 patients in the T-tube and stenting groups, respectively. The 2 groups were comparable with respect to their demographic profile and disease characteristics. Patients in the stent group had a significantly shorter operative time and postoperative stay with an earlier return to normal activity (P<0.0001). CONCLUSIONS Choledochotomy closure over a stent results in a shorter postoperative stay and an earlier return to normal activity compared with closure over a T-tube without any increase in morbidity.
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El-Geidie AAR. Is the use of T-tube necessary after laparoscopic choledochotomy? J Gastrointest Surg 2010; 14:844-8. [PMID: 20232173 DOI: 10.1007/s11605-009-1133-y] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2009] [Accepted: 12/04/2009] [Indexed: 01/31/2023]
Abstract
BACKGROUND Traditionally, the common bile duct (CBD) is closed with T-tube drainage after choledochotomy and removal of CBD stones. However, the insertion of a T-tube is not without complication. AIM OF WORK This randomized study was designed to compare the use of T-tube and primary closure of choledochotomy after laparoscopic choledochotomy to determine whether primary closure can be as safe as closure with T-tube drainage. METHODS Between February 2006 and June 2009, 122 consecutive patients with proven choledocholithiasis had laparoscopic choledochotomy. They were randomized into two equal groups: T-tube (n = 61) and primary closure (n = 61). Demographic data, intraoperative findings, postoperative complications, and postoperative stay were recorded. RESULTS There was no mortality in both groups. There were no differences in the demographic characteristics or clinical presentations between the two groups. Compared with the T-tube group, the operative time and postoperative stay were significantly shorter and the incidences of overall postoperative complications and biliary complications were statistically and significantly lower in the primary closure group. CONCLUSION Laparoscopic common bile duct exploration with primary closure without external drainage after laparoscopic choledochotomy is feasible, safe, and cost-effective. After verification of ductal clearance, the CBD could be closed primarily without T-tube insertion.
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Huang J, Zhu J. Spontaneously removed endobiliary J stent drainage after laparoscopic common bile duct exploration. Surg Endosc 2009; 23:1398-402. [PMID: 19263135 DOI: 10.1007/s00464-009-0368-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2008] [Revised: 12/22/2008] [Accepted: 01/12/2009] [Indexed: 01/13/2023]
Abstract
BACKGROUND Given the limitations and risks associated with current treatments for common bile duct (CBD) stones, the authors placed a spontaneously removed endobiliary J stent in the distal CBD to decompress the biliary tract and performed a primary closure of the CBD after laparoscopic common bile duct exploration (LCBDE). METHODS In this study, 10 of 14 patients with a diagnosis of choledocholithiasis were successfully treated using LCBDE. After extraction of the CBD stones using a choledoscope, a J-shaped stent was placed into the distal CBD as an internal drainage. The J stent was fixed with a rapid absorbable suture at the choledochotomy, which was closed by primary suture. RESULTS The procedures for all 10 patients were successfully completed. No complications related to placement of the endobiliary J stents were observed postoperatively. None of the patients reported discomfort, and the J stents passed spontaneously 2 to 3 weeks after discharge. CONCLUSION Spontaneously removed endobiliary J-stent drainage is a safe and effective surgical technique that allows for straightforward postoperative management after LCBDE.
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Affiliation(s)
- Jianping Huang
- Department of Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, PuAn Road 185, Shanghai, China
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Tian MG, Shi WJ, Zhong CJ, Zhang XW, Chen TM. Laparoscopic treatment of choledocholithiasis with novel self-releasing biliary stent. J Laparoendosc Adv Surg Tech A 2009; 19:405-8. [PMID: 19215211 DOI: 10.1089/lap.2008.0048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the effect of a self-releasing biliary stent antegradely placed during laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis. MATERIALS AND METHODS The soft biliary stent, made of polyurethane, was designed as a J-umbrella form with a pigtailed duodenal part and an umbrella-like biliary anchoring part shaped with the rapidly absorbable suture. After the clearance of stones during LCBDE, a guide wire was inserted into the duodenum through the choledochoscope. The stent was advanced over the guide wire until the pigtail of the stent entered the duodenum. The choledochotomy was primarily closed. RESULTS This technique has been performed on 33 patients with choledocholithiasis. The median length of postoperative hospital stay was 4.3 (3-8) days. All the stents were eliminated from the bile ducts and discharged out of the body. The median time of the stent stay in the body was 13.6 (+/- 2.55) days. Transient hyperamylasemia occurred in 4 of the 33 (12.1%) patients, and stent occlusion occurred in 1 patient who recovered soon after treatment. No bile leak, biliary infection, or stent dislocation was observed. During the follow-up of 12 months, no biliary infection, residual calculi, or stricture occurred. CONCLUSION This novel self-releasing stent is safe and effective in the laparoscopic treatment of choledocholithiasis, and the subsequent removal of the stent can be avoided.
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Affiliation(s)
- Ming Guo Tian
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Nantong University, Nantong, China.
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Chiappetta-Porras LT, Nápoli ED, Canullán CM, Roff HE, Quesada BM, Hernández NA, Petracchi JE, Oría AS. [Single-stage management of common duct stones by video-assisted laparoscopy. Analysis of 10 years' experience]. Cir Esp 2008; 82:231-4. [PMID: 17942049 DOI: 10.1016/s0009-739x(07)71712-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The management of patients with gallstone disease and ductal calculi is controversial. The main options are one-stage or two-stage management. MATERIAL AND METHOD We performed a retrospective analysis of the experience gained over 10 years in the one-stage management of common duct stones in a high-volume tertiary hospital. RESULTS A total of 569 patients were initially treated by laparoscopy. Of these, 412 (76.3%) underwent the transcystic approach, 128 (23.7%) underwent laparoscopic choledochotomy and 29 (5%) were converted to open surgery. Overall morbidity and mortality were 2.46% and 0.52%, respectively. CONCLUSIONS In high-volume centers, one-stage laparoscopic management of common duct stones is safe and feasible, with a high proportion of patients that only require a transcystic approach.
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Zhang HF, Hu SY, Zhang GY, Wang KX, Chen B, Li B. Laparoscopic primary choledochorrhaphy over endonasobiliary drainage tubes. Surg Endosc 2007; 21:2115-7. [PMID: 17514401 DOI: 10.1007/s00464-007-9299-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2007] [Revised: 01/16/2007] [Accepted: 01/22/2007] [Indexed: 01/15/2023]
Abstract
BACKGROUND The T-tube is widely used in laparoscopic choledochotomy to decompress the biliary tree. However, there are high morbidity rates related to the T-tube. This study reviewed the results of laparoscopic primary choledochorrhaphy over endonasobiliary drainage (ENBD) tubes to find an effective alternative to the T-tube for the performance of laparoscopic choledochotomy. METHODS From March 2003 to September 2005, 23 patients (9 men and 14 women) with choledocholithiasis underwent laparoscopic choledochotomy over ENBD tubes. The mean age of these patients was 47 years (range, 32-73 years). At admission, six patients had cholangitis. All the patients had ENBD tubes placed preoperatively after the failure of endoscopic sphincterotomy. RESULTS There was no conversion to open surgery. The mean operative time was 90 min (range, 70-150 min). There were no biliary complications such as bile leaks, biliary peritonitis, or pancreatitis. No residual stones were found by postoperative cholangiograms. The ENBD tubes were removed between postoperative days 7 and 9. The hospital stay ranged from 8 to 14 days, with 16 patients (70%) discharged on postoperative day 8. The complications were limited to one umbilical infection and one case of pneumonia. The median follow-up period was 24 months (range, 8-36 months), and none of the patients were readmitted with biliary symptoms. CONCLUSION Laparoscopic choledochotomy over ENBD tubes proved to be technically feasible and safe. The ENBD tube decompresses the biliary tree and allows for cholangiography after surgery. Its removal does not need to wait for tract maturation, which allows an earlier removal of the tube and a shorter postoperative hospital stay. Laparoscopic choledochotomy over ENBD tubes is an effective alternative to the T-tube in laparoscopic choledochotomy.
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Affiliation(s)
- H-F Zhang
- Department of General Surgery, Qilu Hospital of Shandong University, Wenhua Xi Road 107#, Jinan, 250012, People's Republic of China
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Abstract
BACKGROUND Recent reports have noted that postoperative complications following open or laparoscopic choledochotomy for common bile duct (CBD) exploration are mainly related to the T-tube presence, and that there has been no trend of decrease in the laparoscopic era. Laparoscopic endobiliary stent placement with primary closure of the CBD has been proposed as a safe and effective alternative to T-tube placement. METHODS Between January 1999 and January 2003, 53 consecutive patients suffering from proven choledocholithiasis underwent laparoscopic common bile exploration (LCBDE) via choledochotomy. In the early period, a T-tube was placed at the end of the procedure (group A, n = 32) while, from June 2001 onwards, laparoscopic biliary stent placement and primary CBD closure were chosen as the drainage method (group B, n = 21). RESULTS Six patients developed T-tube-related complications postoperatively. Univariate analysis revealed statistically significant lower morbidity rate and shorter postoperative hospital stay for the stent group. Although not statistically significant, a median saving of 780 UK pounds per patient was observed in the stent group. CONCLUSION Biliary endoprosthesis placement following laparoscopic choledochotomy avoids the well-known complications of a T-tube, leading to a shorter postoperative hospital stay. The method is safe and effective and it should also be considered as cost-effective compared to T-tube placement. Further studies are required in order to document cost-effectiveness of the method.
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Affiliation(s)
- John Griniatsos
- Upper GI and Laparoscopic Unit, Ealing Hospital, Southall Middlesex, London, UK.
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Abstract
AIM: Transcystic biliary decompression (TCBD) has been proposed as an alternative to T-tube placement after laparoscopic choledochotomy (LCD). This permits safe primary closure of the choledochotomy and eliminates the complications associated with T-tubes. TCBD tube has been secured by Roeder knots and transfixation, and removed later than 3 wk after surgery. We presented a modified TCBD (mTCBD) method after LCD using the ureteral catheter and the Lapro-Clip (David and Geck, Danbury, Connecticut, USA), and compared it with T-tube drainage.
METHODS: Between October 2002 and June 2003, patients with choledocholithiasis undergoing LCD with mTCBD (mTCBD Group, n = 30) were retrospectively compared to those undergoing LCD with T-tube drainage (T-tube Group, n = 52) at a single institution.
RESULTS: There were no significant differences in operative time and retained stones between the two groups. Patients in mTCBD group had a significantly decreased average output of bile compared with those in T-tube group (306 ± 141 vs 409 ± 243 mL/24 h, P = 0.000). Removal of drain tubes in mTCBD group was done significantly earlier than that in T-tube group (median, 5 vs 29 d, P = 0.000). No complication related to drain tubes was found in mTCBD group, and morbidity rate with the T-tube was significantly higher (11.5%), and bile leakage following T-tube removal was 5.8%.
CONCLUSION: A modified TCBD after LCD is safe, effective and easy to perform. It may reduce postoperative complications, especially bile leakage.
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Affiliation(s)
- Qi Wei
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou 310016, Zhejiang Province, China.
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Isla AM, Griniatsos J, Karvounis E, Arbuckle JD. Advantages of laparoscopic stented choledochorrhaphy over T-tube placement. Br J Surg 2004; 91:862-6. [PMID: 15227692 DOI: 10.1002/bjs.4571] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Abstract
Background
Postoperative complications after laparoscopic choledochotomy are mainly related to the T tube. Both laparoscopic endobiliary stent placement with primary closure of the common bile duct (CBD) and primary closure of the CBD without drainage have been proposed as safe and effective alternatives to T-tube placement.
Methods
This was a retrospective analysis of data collected prospectively on 53 consecutive patients suffering from proven choledocholithiasis who underwent laparoscopic CBD exploration through a choledochotomy between January 1999 and January 2003. In the early period a T-tube was placed at the end of the procedure (n = 32). Biliary stent placement and primary CBD closure was performed from June 2001 (n = 21).
Results
There were no significant differences in epidemiological characteristics, preoperative factors or intraoperative findings between the groups. Seven patients developed complications, six in the T-tube group and one in the stent group. Univariate analysis revealed a significantly lower morbidity rate and shorter postoperative hospital stay in the stent group.
Conclusion
Placement of a biliary endoprosthesis after laparoscopic choledochotomy achieves biliary decompression, and avoids the complications of a T tube, leading to a shorter postoperative hospital stay. The method is a safe and effective alternative method of CBD drainage after laparoscopic choledochotomy.
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Affiliation(s)
- A M Isla
- Upper Gastrointestinal and Laparoscopic Unit, Ealing and Charing Cross Hospitals, London, UK.
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16
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Wu JS, Soper NJ. Comparison of laparoscopic choledochotomy closure techniques. Surg Endosc 2002; 16:1309-13. [PMID: 12235508 DOI: 10.1007/s004640080016] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2002] [Accepted: 03/26/2002] [Indexed: 12/26/2022]
Abstract
BACKGROUND Laparoscopic common bile duct exploration (CBDE) has traditionally been accompanied by T-tube drainage. However, other methods of choledochotomy closures have been reported. This study compared three laparoscopic methods of choledochotomy closure in a prospective, randomized fashion to determine which method should be the preferred technique. METHODS In this porcine model, 24 animals initially underwent laparoscopic common bile duct (CBD) clipping to simulate an obstruction. Two days later, the animals underwent laparoscopic clip removal and simulated CBDE through a 1.5-cm choledochotomy. The animals were then randomized to one of three groups: primary choledochotomy closure (group I), antegrade CBD stenting with primary closure (group II), or T-tube placement (group III). To assess for CBD stenoses and leaks, the animals were killed 2 months postoperatively, at which time a cholangiogram was performed and the bile duct harvested. The ratio of proximal CBD to choledochotomy site was assessed radiographically and histologically. RESULTS The operative time was significantly longer in group III (200 +/- 13 min, p < 0.05) than in group I (141 +/- 17 min) and group II (154 +/- 16 min). The ratio of the proximal CBD diameter to the choledochotomy site diameter by cholangiogram was 2.1:1.0 in group I, to 1.2:1.0 in group II, and 1.1:1.0 in group III (p < 0.01). The ratio of the proximal CBD intraluminal area to the choledochotomy site intraluminal area was 2.1:1.0 in group I compared to 1.1:1.0 in groups II and III (p < 0.01). None of the animals developed jaundice or sepsis. CONCLUSION Significant stenoses were present at the choledochotomy site in the primary closure group, and T-tube placement resulted in prolonged operative times. We conclude that laparoscopic antegrade CBD stenting with primary closure of the choledochotomy site is the preferred technique after choledochotomy in an animal model. Further assessment in a clinical trial is warranted.
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Affiliation(s)
- J S Wu
- Department of Surgery, Kaiser Permanente Medical Center, University of California-San Diego, 4647 Zion Avenue, San Diego, CA 92130, USA
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Isla AM, Griniatsos J, Wan A. A technique for safe placement of a biliary endoprosthesis after laparoscopic choledochotomy. J Laparoendosc Adv Surg Tech A 2002; 12:207-11. [PMID: 12184908 DOI: 10.1089/10926420260188128] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Biliary endoprosthesis has been proposed as an alternative to T-tube placement after laparoscopic choledochotomy in an attempt to eliminate the complications associated with T-tubes. Biliary endoprostheses have been, until now, placed under fluoroscopic guidance. We present a modification of Gersin's method for endoprosthesis placement under direct vision. PATIENTS AND METHODS As of July 2001, seven patients who fulfilled the criteria for common bile duct (CBD) exploration through a choledochotomy, a biliary endoprosthesis was inserted under direct vision at the end of the procedure with primary closure of the CBD above it. In all cases, plastic biliary stents 10F in diameter were used ranging from 5 to 10 cm in length. We describe in detail the technique of CBD stent placement using the choledochoscope as the advancing device. We also propose the use of intraoperative cholangiography instead of on-table endoscopy to check the final correct position of the stent. RESULTS The median postoperative hospital stay was 2 days. Two patients developed transient hyperamylasemia in the immediate postoperative period. None of the patients developed short-term complications (<30 days), namely bile leak, CBD erosion, stent occlusion, or stent migration. The long-term results revealed early return to full daily activities and normal liver function tests. Stents were removed endoscopically 4 weeks after the initial procedure except in two patients who spontaneously passed them. CONCLUSION We propose a 10F 10-cm biliary endoprosthesis placed under direct vision as a safe, effective, time-sparing, and cost-effective adjunct to CBD exploration through a choledochotomy. Placement of the endoprosthesis is associated with low morbidity and eliminates the complications related to T-tubes.
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Affiliation(s)
- A M Isla
- Upper GI and Laparoscopic Unit, Ealing Hospital, Southall, Middlesex, London, United Kingdom.
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