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Background: Treatment of common bile duct stones (CBDS) includes laparoscopic cholecystectomy (LC) with either laparoscopic common bile duct exploration (LCBDE) or perioperative endoscopic retrograde cholangiopancreatography (ERCP). The main objective of this study was to identify predictive factors for the failure of upfront and exclusive surgical treatment by LCBDE., Methods: This is a single-center, retrospective study on patients with CBDS and operated for LC between 2007 and 2019. The use of intra- or postoperative endoscopy for CBD clearance within 6 months after surgery was considered as failure of LCBDE. Predictors for the failure of LCBDE were investigated and outcomes were compared., Results: Among 222 operated patients, LCBDE was successfully performed in 173 patients (78%) and 49 (22%) required ERCP with sphincterotomy (intraoperative (n=29) or postoperative (n=20)). Independent risk factors for surgical failure were male sex (OR: 2.525 (1.111-5.738); p=0.027), anesthesia induction time ≥ 4 p.m. (OR: 4.858 (1.731-13.631); p=0.003), pediculitis (OR: 4.147 (1.177-14.606); p=0.027), and thin CDB < 4mm (OR: 11.951 (3.562-40.097), p< 0.0001). Age, ASA score, cystic anatomy, presence of cholecystitis, and the surgeon's experience were not identified as predictors for surgical failure. A general anesthesia number >1 (6% vs. 33%; p < 0.0001), length of initial stay (6 [1-42] vs. 8 [2-27], p=0.012), total length of hospitalization (6 [1-45] vs. 9 [2-27]; p=0.010), and the rate of emergency readmissions (3.5% vs. 12.2%; p=0.027) were significantly higher in the LCBDE failure group., Conclusions: Upfront LCBDE for CBDS was associated with improved outcomes compared to intra-/postoperative ERCP recourse. Male sex, pediculitis, thin CBD, and surgery later than 4 p.m were associated with LCBDE failure and the need for endoscopic treatment., Registration Number and Agency: The present retrospective study was approved by our local ethics committee and was declared on ClinicalTrials.gov (ID: NCT04467710)., (© 2023. The Society for Surgery of the Alimentary Tract.)

Whether for a diagnostic evaluation or for the treatment of common bile duct lithiasis, the laparoscopic approach is the most efficient method compared with the other alternatives. The authors describe in the present article the method to treat laparoscopically common bile duct lithiasis.

At the time of cholecystectomy for symptomatic cholelithiasis, 7-20% of patients have common bile duct stones. Nearly one third of them are asymptomatic. Routine cholangiography during cholecystectomy allows the diagnosis and treatment of common bile duct stones during the same operation. Selective indication for the diagnosis of common bile duct stones based on the positive predictive value of indicators limits treatment to symptomatic cases. No single indicator is however completely accurate in predicting common bile duct stones and the natural history of asymptomatic cases is uncertain. Endoscopic stone extraction preceding cholecystectomy is not superior to one-stage surgical treatment. Diagnosis and treatment of common bile duct stones are feasible laparoscopically. Complications of common bile duct stones are cholangitis and acute pancreatitis; if severe, they require specific therapeutic approaches.

Laparoscopic exploration of the common bile duct (CBD) is performed either for the diagnosis or the treatment of CBD stones. Laparoscopic intraoperative cholangiography (IOC) versus ultrasonography (LUS) and laparoscopic versus endoscopic extraction of CBD stones were compared through a review of the prospective, comparative studies, randomized or not, evaluating these different techniques. Cystic duct cholangiography and fluoroscopic imaging are the standards for IOC. The potential protective effect of IOC regarding the risk or severity of CBD injuries might be the major argument for a routine use of laparoscopic IOC. Most if not all the purported advantages of LUS versus IOC for the diagnosis of CBD stones remain to be proven. Laparoscopic intraoperative diagnosis of CBD stones by cholangiography or ultrasonography followed by the laparoscopic extraction or, in case of failure, by postoperative endoscopic sphincterotomy, might represent the future for the diagnosis and treatment of CBD stones., (Copyright 2000 by W.B. Saunders Company.)

Limitation for preoperative ERCP/ES before laparoscopic cholecystectomy in patients scheduled for laparoscopic cholecystectomy are (1) Additional invasiveness of endoscopic procedures in patients supposed to be fitted for surgery, (2) A high rate of useless procedures due to the low predictive value of suspicion criteria for common bile duct stones (CBDS), (3) an inability to detect and treat all patients with CBDS, and (4) so far, an absence of demonstration of the superiority of this split therapeutic approach versus a one stage surgical treatment. Published series of CBDS extraction during laparoscopic cholecystectomy have included more than 2000 patients. Results and complications of this one stage laparoscopic approach compares favourably to the conventional open surgical treatment. In one randomized trial endoscopy plus laparoscopy was not demonstrated superior to laparoscopy alone. Intraoperative diagnosis and treatment of CBDS during laparoscopic cholecystectomy is the most cost efficient approach for patients with or without preoperative suspicion of CBDS, provide they are fitted for surgery.

Background: Several technical approaches for laparoscopic CBD exploration (LCBDE) exist. Laparoscopic choledochotomy is required in some situations and whenever a transcystic approach fails. Biliary drainage after choledochotomy has a 5% morbidity rate and avoidance of biliary drains might therefore further improve the results of LCBDE. The authors report a prospective multicentric evaluation of laparoscopic choledochotomy with completion choledochoscopy and primary duct closure without any biliary drainage. Methods: Between October 1991 and December 1997, 100 patients from four surgical centers underwent this approach for CBD stones. Choledocholithiasis had been demonstrated preoperatively in 35 patients (35%), suspected in 52 and was incidentally found during routine intraoperative cholangiography in 13 patients. External ultrasound was the only preoperative imaging investigation in 87 patients. LCBDE was attempted irrespective of age, ASA score, or the circumstances leading to the preoperative diagnosis or suspicion of CBD stones (acute cholecystitis in 33% of patients, cholangitis in 10%, or mild acute pancreatitis in 6% of all patients). Results: The technique was equally feasible in all participating centers (University hospital, general hospital, or private practices). Vacuity of the CBD was achieved in all patients without mortality. Eleven patients had complications and 3 patients required a laparoscopic reintervention. Median postoperative hospital stay was 6 days (range: 1–26). No patient required additional CBD procedures during follow-up. Conclusions: In case of LCBDE, choledochotomy with primary closure without external drainage of the CBD is a safe and efficient alternative, even in patients with acute cholecystitis, cholangitis, or pancreatitis, provided that choledochoscopy visualizes a patent CBD. This technique is applicable in all types of medical institutions if required laparoscopic skills and equipment are available. [ABSTRACT FROM AUTHOR]