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Background: Choledocholithiasis is the most common cause of acute cholangitis which resulted in potentially life-threatening infection. The prevalence of common bile duct (CBD) stone increases with age.[1] Common bile duct exploration (CBDE) is one of the treatments. However, there are a few studies about this procedure in the elderly patients. Hence, we discover the outcomes of CBDE in elderly patients ≥70 years). The methods of CBDE, including open and laparoscopic (LC) method were also compared. Material and Method: From January 2009 to December 2014, the elderly patients with proven choledocholithiasis who underwent CBDE were included. The deremographical information, surgical outcome and postoperative complication were all recorded and evaluated. Result: There were 97 patients in open method group (Group A) and 21 patients in LC method group (Group B). The mean age was 76.9 years (70–93 years). The demographics and comorbidity in both groups were similar. The mean length of stay after operation for Group A was 11.2 ± 9.0 days and Group B was 5.67 ± 2.29 days (P < 0.0001). The complication rate was similar in both groups (Group A, 22.6%; Group B, 4.76%; P = 0.07). The overall complication and mortality rate was 19.5% and 0.8%, respectively. The clearance of CBD stone was 95.9% in Group A and 95.2% in Group B (P = 1.00). Conclusion: CBDE can be performed safely in the elderly with accepted morbidity and mortality, and the stone clearance is also reliable. The LCBDE approach is safe in these elderly and has benefit for shortening the hospital stay.

A 50-year-old female presented to us with features of obstructive jaundice. Investigations revealed cholelithiasis with single large impacted calculus in the common bile duct (CBD) and significant dilatation of extrahepatic biliary tree. Incidentally, the patient was also detected to have situs inversus totalis (SIT). Attempt at extraction of the calculus in the CBD by endoscopic retrograde cholangiography failed, and a 7F stent was placed. The patient was subjected to laparoscopic cholecystectomy, CBD exploration with the extraction of the offending calculus and laparoscopic choledochoduodenostomy (LCDD). The patient had an uneventful recovery and is since discharged. PubMed search did not reveal LCDD in SIT as a procedure reported in literature to the best of our knowledge.

Background: Common bile duct stones (CBDS) are treated with endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) or with the single-stage laparoscopic common bile duct exploration (LCBDE) and LC. Multiple ERCP attempts and failure increase the risk of postprocedural complications. In such circumstances surgery is advocated. The aim of the study is to compare the outcome of LCBDE and LC in patients who had never had an ERCP, to that of patients who underwent previously failed ERCP. Methods: A retrospective analysis of 54 patients undergoing LCBDE and LC between 2010 and 2017, was performed. Patients were divided in 2 groups: primary surgery (group 1), surgery after failed ERCP (group 2). Demographics and preoperative investigation results were collected. Comparative outcomes were common bile duct (CBD) clearance rate, operative time, conversion to open rate, postoperative morbidity, mortality, and hospital stay. Data were evaluated with the Student's t, Chi-square, or Fisher's tests. Results were considered as statistically significant when P < .05. Results: In both groups CBD clearance was above 90%. The mean operative time was longer in group 2 (130.3 minutes ± SD 83.72 vs. 178.73 ± 57.22; P < .05). There was no difference in the conversion to open and postoperative complication rates between groups. A bile leak occurred in 2 patients from group 1, 3, from group 2. No postoperative mortality occurred. The median hospital stay was longer in group 2 (2 days ± SD 2.54 vs. 5 ± 5.77; P < .05). Conclusions: LCBDE and LC is safe and effective in patients who had previous failed ERCP. If ERCP failure is anticipated and/or the risk of post-ERCP complications is high, surgery should be considered as the first-line treatment of CBDS. Longer intraoperative time and hospital stay are expected. [ABSTRACT FROM AUTHOR]

Laparoscopic intraoperative cholangiogram (IOC) with common bile duct exploration (CBDE) and endoscopic retrograde cholangiopancreatography (ERCP) are two therapeutic techniques for choledocholithiasis. The preferred technique is unclear. We identified subjects who underwent laparoscopic cholecystectomy (LC) and IOC/CBDE or ERCP from July 1, 2006, to December 31, 2016. We retrospectively reviewed 81 patients (≤ 18 y) who received these interventions for suspected choledocholithiasis. Main outcomes analyzed were success of intervention and complications. Of the 81 patients, 21 ERCPs and three endoscopic ultrasounds (EUSs) were performed before LC. Eighteen of 21 (85.7%) patients had stones or sludge cleared by ERCP, whereas 3 (14.3%) had normal common bile ducts without evidence of stones. Five of 24 (20.8%) had significant post-ERCP complications. Seven of 24 (29.2%) had more than one admission. Sixty of 81 patients underwent LC with IOC ± CBDE. Twenty one of 60 (36.2%) were found to have abnormal IOC. Eight of 15 (53.3%) attempted laparoscopic CBDE were successful. Eleven of 21 (52.4%) patients with abnormal IOC had post-LC ERCP (10) and EUS (1). Patients admitted to the Pediatric Surgery service were more likely to undergo LC first than ERCP/EUS (OR 3.46, 95% CI 1.26 to 9.45, P = 0.016). Patients undergoing LC first had a shorter length of stay (mean LOS 5.13 d versus 4.07, median 5.0 versus 3.0 d, P -value < 0.05). Successful and safe laparoscopic treatment of choledocholithiasis is possible in the pediatric patient. A laparoscopic-first approach to suspected choledocholithiasis may reduce the number of procedures needed in this patient population. [ABSTRACT FROM AUTHOR]

Background: The present study aimed to explore the indications and feasibility of T‐tube‐free trans‐umbilical single‐incision laparoscopic common bile duct exploration (SILCBDE) plus laparoscopic cholecystectomy (LC) for treating choledocholithiasis. Methods: Patients hospitalized in the Second Affiliated Hospital (Shengjing Hospital) of China Medical University from January 2010 to January 2017 with the diagnosis of common bile duct stones and treated with T‐tube‐free trans‐umbilical single‐incision LC plus common bile duct exploration were retrospectively analysed. Results: A total of 37 male/female choledocholithiasis patients (mean age 65 years, range 29–86) were treated with T‐tube‐free trans‐umbilical SILCBDE plus LC. No intraoperative complication or conversion to open surgery occurred in any of the cases. The mean operative time was 99.8 min (range 84–125) for endoscopic nasobiliary drainage group (n = 6), 113.8 min (range 70–150) for endoscopic retrogradebiliary drainage group (n = 2), 131.1 min (range 75–161) for pigtail J‐tube group (n = 24), 113.7 min (range 100–150) for primary closure group (n = 5). The mean post‐operative hospital stay length was 5.5 days (range 4–7) for endoscopic nasobiliary drainage group, 12.5 days (range 10–15) for endoscopic retrogradebiliary drainage group, 6.5 days (range 4–10) for J‐tube group, 5.8 days (range 4–9) for primary closure group. Pancreatitis, bile leakage and peritonitis were not presented in any of the group. After 17–101 months follow‐up, three patients presented recurrent common bile duct stones. Conclusion: In selected cases, T‐tube‐free trans‐umbilical SILCBDE plus LC is feasible and safe for experienced surgeons, and can achieve similar therapeutic effects as common LC plus common bile duct exploration procedures. [ABSTRACT FROM AUTHOR]

The 203 patients who underwent laparoscopic common bile duct exploration for choledocholithiasis were retrospectively analyzed. The patients were divided into internal drainage tube group (n=87) and T-tube group (n=116). Total bilirubin, direct bilirubin, alanine aminotransferase (AST), aspartate aminotransferase (ALT), the diameter of common bile duct, number of stones, operation time, intraoperative bleeding, postoperative hospital stay and postoperative complications were compared between the two groups. Possible influencing factors were selected as independent variables, and the operation mode was selected as the dependent variable for multifactor unconditional logistic regression analysis. There were no significant differences in the sex, age, total bilirubin, direct bilirubin, AST, ALT, operation time, intraoperative blood loss, postoperative hospital stay and postoperative biliary leaks between the two groups (P>0.05). The diameter of the common bile duct was smaller and the incidence of multiple stones in the common bile duct was lower in the internal drainage tube group compared with that in the T-tube group (P<0.05). The results of multifactor unconditional logistic regression analysis demonstrated that the diameter of the common bile duct and the number of stones in the common bile duct were associated with the operation mode as influencing factors. In conclusion, Patients with multiple stones in the common bile duct or with a wide diameter of the common bile duct are more likely to have T-tube placed rather than an internal drainage tube. [ABSTRACT FROM AUTHOR]

Background Choledocholithiasis is a common surgical presentation with an incidence of 8% to 16% in symptomatic cholelithiasis. Treatment often requires a multi-stage approach via endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC), which can prolong the length of stay (LoS) and expose patients to unnecessary risks. A single-stage procedure, such as LC with common bile duct exploration (CBDE), is a safe and effective option that may decrease LoS. This study compares patient outcomes and management in a regional center and aims to identify factors that predict the presence of confirmed choledocholithiasis. Methods A retrospective cross-sectional analysis was performed on all patients admitted to Toowoomba Hospital for management of diagnosed or suspected choledocholithiasis from January 2021 to March 2023. Patient demographics, ERCP findings, and operative data were collated. Results A total of 195 patients were identified, including 136 patients undergoing multi-stage management, 34 patients who had an ERCP alone, and 25 patients who underwent single-stage management. Single-stage procedures had an 80% success rate with an average LoS of 3.6 days. Multi-stage procedures had an average LoS of 8.1 days and an ERCP success rate of 93%. Complication rates between ERCP (11.7%) and LC with CBDE (9.7%) were comparable. Time to index ERCP and serum bilirubin level were found to be significantly lower in those with positive index ERCP findings compared to those without. Conclusion Single-stage procedures are a safe way to manage choledocholithiasis and are associated with a reduced LoS when compared to multi-stage management, with comparable efficacy and morbidity rates., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Zouki et al.)

Background: Primary closure after laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration (LCBDE) is a safe and effective approach for treating cholecystolithiasis with choledocholithiasis. The aim of this study was to evaluate the learning curve of performing primary closure after LC+LCBDE.Methods: We retrospectively identified all patients who underwent primary closure after LC+LCBDE performed by a single surgeon from January 2009 to April 2015 in our institution, and analyzed preoperative, intraoperative, and postoperative data using the cumulative sum (CUSUM) analysis to evaluate the learning curve for this procedure.Results: Overall, there were 390 patients. The total postoperative complications rate was 7.2%, including bile leakage in 9 (2.3%) patients and retained common bile duct stone in 3 (0.8%) patients. The CUSUM operating time (OT) learning curve was best modeled by the equation: CUSUMOT = 312.209 × procedure0.599 × e(-0.011×procedure) + 122.608 (R2 = 0.96). The learning curve was composed of two phases, phase 1 (the initial 54 patients) and phase 2 (the remaining 336 patients). A significant decrease in the OT (116.8 ± 22.4 vs. 93.8 ± 17.8 min; p < 0.001) and complication rate (16.7 vs. 5.7%; p < 0.01) including the rate of bile leakage (7.4 vs. 1.5%; p < 0.01) and retained stone (3.7 vs. 0.3%; p < 0.01) was observed between the two phases. In addition, 20 patients had conversion to open surgery. Impacted stones were independently associated with conversion, as indicated by a multivariable analysis.Conclusion: The data suggest that the learning curve of this procedure was achieved in approximately 54 cases. An impacted stone was the only risk factor that affected the conversion rate. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic common bile duct exploration (LCBDE) is used to treat choledocholithiasis. Flexible choledochoscopy is usually performed; however, this instrument is fragile and liable to breakage.Materials and Methods: Data were collected and reviewed retrospectively from a prospectively maintained database. All cases of attempted LCBDE with the rigid ureteroscope at the institution since January 2014 were included. Demographic characteristics, preoperative attempted endoscopic retrograde cholangiopancreatography (ERCP), size of the bile duct, findings at laparoscopy, use of drain or T-tube, conversions, and morbidity or mortality were documented.Results: A total of 37 patients were identified. The median age was 51 years (32-71). The male to female ratio was 1:5. Twenty-eight patients had failed ductal clearance at ERCP (75.7%). The mean common bile duct (CBD) diameter was 11.4 mm (10-13.5). There were five conversions. Cirrhosis in 2 patients, bleeding in 1 patient, impacted stone in 1, and equipment failure in 1. T-tubes were placed in 5% of cases. N = 8 (21.6%) of the patients had a Mirizzi syndrome. Average hospital stay was 4 days (3-7). Two patients had complications postoperatively-bleeding and collections.Conclusions: LCBDE using the rigid ureteroscope is feasible. It can be performed with acceptable morbidity. Use of the rigid ureteroscope represents a good alternative to the flexible choledochoscope with high duct clearance rates. One disadvantage is cirrhosis where the scope may not be negotiated into the CBD due to a stiff liver. It is a viable option when preoperative ERCP has failed to clear the CBD. [ABSTRACT FROM AUTHOR]

Common bile duct (CBD) stones are common in elderly patients. The laparoscopic transcystic approach with micro-incision of the cystic duct confluence in common bile duct exploration (LTM-CBDE) is a modified laparoscopic transcystic approach. Its safety and efficacy have not been studied in elderly patients with secondary choledocholithiasis. This study evaluates the safety and efficacy of LTM-CBDE in elderly (≥65 years) patients with secondary choledocholithiasis and compares the results with those in younger patients. In this retrospective analysis, 128 patients underwent LTM-CBDE from March 2007 to December 2013. The patients were divided into two groups according to age: the elderly group consisted of 50 patients aged ≥65 years and the younger group consisted of 78 patients aged <65 years. The preoperative morbidity rate, American Society of Anesthesiologists (ASA) score, previous abdominal operations, operation time, postoperative hospital stay, open conversion rate, postoperative complication rate, residual stone rate, recurrence rate and mortality were compared in both groups. The preoperative morbidity (41 vs. 28) and ASA score (2.5 ± 0.7 vs. 1.8 ± 0.6) were higher in the elderly group (P = 0.000, in both groups). No significant differences in previous abdominal operations, operation time, postoperative hospital stay, open conversion rate, postoperative complication rate, residual stone rate, recurrence rate and mortality (P > 0.05) were found between the two groups from March 2007 to December 2013. LTM-CBDE is a safe and effective treatment procedure for elderly patients with secondary choledocholithiasis. For suitable patients, we recommend LTM-CBDE as the treatment of choice. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study is to evaluate the clinical outcomes and cost-effectiveness of elective, robot-assisted choledochotomy and common bile duct exploration (RCD/CBDE) compared to open surgery for ERCP refractory choledocholithiasis.Method: A prospective database of all RCD/CBDE has been maintained since our first procedure in April 2007 though April 2016. With ethics approval, this database was compared with all contemporaneous elective open procedures (OCD/CBDE) performed since March 2005. Emergency procedures were excluded from analysis. Cost analysis was calculated using a micro-costing approach. Outcomes were analyzed on the basis of intent-to-treat. A p value of 0.05 denoted statistical significance.Results: A total of 80 cases were performed since 2005 compromising 50 consecutive, unselected RCD/CBDE and 30 OCD/CBDE. Comparing RCD/CBDE to OCD/CBDE there were no significant differences between groups with respect to age (65 ± 20 vs. 67 ± 18 years, p = 0.09), gender (14/30 vs. 16/25 male/female, p = 0.52), ASA class or co-morbidities. The mean duration of surgery for RCD/CBDE trended longer compared to OCD/CBDE (205 ± 70 min vs. 174 ± 73 min, p = 0.08). However, there was significant reduction in postoperative complications with RCD/CBDE versus OCD/CBDE (22% vs. 56%, p = 0.002). Median hospital stay was also significantly reduced (6 vs 12 days, p = 0.01). The net overall hospital cost for RCD/CBDE was lower ($8449.88 CAD vs. $11671.2 CAD).Conclusion: In this single-centre, cohort study, robotic-assisted CD/CBDE for ERCP refractory common bile duct stones provides the dominating strategy of improved patient outcomes with a reduction of overall cost. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic surgery for choledocholithiasis is still evolving. Only a few reports of single-incision laparoscopic common bile duct exploration (LCBDE) have been published.Methods: One hundred and one consecutive patients underwent single-incision LCBDE (SILCBDE) by one surgeon with straight instruments during a 42-month period.Results: Choledochotomies were performed on 61 patients (60.4%). The success rate of intrahepatic duct exploration was 68.0% (17/25) for patients undergoing transcystic choledochoscopic bile duct explorations following longitudinal cystic ductotomies. The ductal clearance rate was 100%. Eighteen procedures (17.8%) were converted, including one open surgery. Nineteen patients (18.8%) experienced 26 episodes of complications; the majority (19 episodes) were classified as Clavien-Dindo grade I. Excluding those patients with Mirizzi syndrome (McSherry type II), multivariate logistic regressions showed that patients who were older or had complicated cholecystitis had higher procedure conversion rates and that higher modified APACHE II scores, higher white blood cell counts, and longer operative times were independent risk factors for complications. Based on operative times, 20 successful SILCBDEs were needed to get through the learning phase. A higher transcystic approach rate (46.5 vs. 8.3%; P < 0.01) and a shorter operative time (207 ± 62 vs. 259 ± 66 min; P < 0.01) were observed in the experienced phase. Compared with our early series of multi-incision LCBDE, the SILCBDE group had a higher bile duct stone clearance rate (100 vs. 94.4%; P < 0.05) and a higher proportion of patients with concomitant acute cholecystitis (59.6 vs. 22.2%; P < 0.01).Conclusions: LCBDE with a 100% ductal clearance rate is possible following an algorithm for various approaches. SILCBDE is feasible under a low threshold for procedure conversion. A transcystic approach should be tried first if indicated, and a longitudinal cystic ductotomy to the cystocholedochal junction is beneficial. Prospective, randomized trials comparing single-incision and multi-incision LCBDE are anticipated. [ABSTRACT FROM AUTHOR]