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A retrospective study of 4628 patients who underwent laparoscopic cholecystectomies with choledocholithotomy with primary repair of common bile duct , with a mean follow-up of 23.2 months is carried outto evaluate the safety and feasibility of laparoscopic choledocholithotomy via choledochotomy for the treatment of choledocholithiasis in Dishari Health Point Private Limited, a multispeciality hospital in Malda from January 2004 to January 2019. We had to convert to open surgery in 27 patients and could complete the operation laparoscopically in rest 4621 patients. We also did open surgery in 30 patients apart from this. We analyse the results and it was found that Laparoscopic bile duct exploration via choledochotomy followed by primary duct closure is feasible and safe for the treatment of choledocholithiasis.

Background: Laparoscopic common bile duct exploration (LCBDE) is an effective treatment for choledocholithiasis. The aim of this study was to determine the predictive factors associated with conversion during LCBDE and to assess the implications of conversion on the patients' postoperative course. Methods: A retrospective cohort study based on patients undergoing LCBDE between 2000 and 2018 was conducted. Uni- and multivariate regression analyses were performed. Results: A total of 357 patients underwent LCBDE, and the conversion rate was 14.2%. The main reasons for conversion were lithiasis extraction (21; 41%) and difficult dissection (13; 26%). Independent predictors for conversion were increasing levels of serum bilirubin prior to surgery (OR=4.745, 95% CI: 1.390-16.198; p=0.013), and emergency setting (OR=4.144, 95% CI: 1.449-11.846; p=0.008). Age was independently associated with lower odds of conversion (OR=0.979, 95% CI: 0.960-0.999; p=0.036). Conversion had a negative impact on the patients' postoperative course, including severe complication (21.6% vs. 5.2% p

Overlapping surgery or double-booking is a vital yet disputed issue in healthcare field. However, safety of the overlapping surgery during laparoscopic common bile duct exploration (LCBDE) remains unclear. This study aimed to assess the clinical outcomes and safety of overlapping surgery during laparoscopic cholecystectomy and LCBDE for gallbladder and common bile duct stones (CBDS).This study retrospectively reviewed 2736 laparoscopic cholecystectomy and LCBDE surgeries during 2013-2020. One thousand, two hundred eighty patients underwent LCBDE through cystic duct, including 867 receiving overlapping procedures, while 1456 underwent LCBDE through laparoscopic choledochotomy (LC), including 981 who underwent overlapping procedures. Data regarding patient sex, age, body mass index, the American Society of Anesthesiology grade, comorbidities, preoperative liver function test, previous upper abdominal surgery, presence of acute cholecystitis, cholangitis, pancreatitis, or jaundice, common bile duct (CBD) or CBDS diameter, CBDS number, LCBDE operation time, procedure duration, length of stay, stone clearance, CBD closure methods, conversion to open surgery, and complications were collected.Differences in demographics and clinical variables between both groups were not significant, and the unadjusted outcomes were comparable, except for the total procedure duration (transcystic:Overlapping surgery in laparoscopic cholecystectomy and LCBDE was safe at our institution. However, the association of patient outcomes with overlapping laparoscopic cholecystectomy and LCBDE should be further investigated.

The extrahepatic biliary tract includes the right, left, and common hepatic ducts; cystic duct; common bile duct; hepatocystic triangle; and the gallbladder. Anomalous hepatic ducts can be a surgically significant source of bile leakage. Detailed step-by-step technique is presented for laparoscopic (robotic) cholecystectomy, intraoperative cholangiogram, common bile duct exploration, open cholecystectomy, sphincteroplasty, choledochoduodenostomy, choledochocystectomy, and hepaticojejunostomy (Hepp-Couinaud) procedure.

Background The ‘gold standard’ for management of gallstones is laparoscopic cholecystectomy, but there is no consensus for treatment of common bile duct stones. There is insufficient information in the literature on the practice of laparoscopic common bile duct exploration (LCBDE) in cases of endoscopically irretrievable stones. This study presents the technical aspects and results of this approach and comparing it with open common bile duct exploration (OCBDE). Aim To assess the management of the patients with calcular obstructive jaundice after failed endoscopic retrograde cholangiopancreatography with LCBDE in comparison with OCBDE. Patients and methods A prospective randomized study was conducted for 2 years started from 2017 to 2019 in Theodor Bilharz Research Institute. A total of 600 patients with calcular obstructive jaundice underwent endoscopic retrograde cholangiopancreatography, with failure of stone extraction in 50 patients. Of them, 30 patients underwent LCBDE and the other 20 patients underwent OCBDE. Overall, 40 patients were female and the other 10 were male. They ranged in age from 23 to 80 years old, with a mean age of 46.72 years. Results The mean postoperative hospital stay, pain score, and analgesia score were significantly short (P 0.05) but with no statistically significant difference. Conclusion LCBDE considered as a safe, efficient and preferred procedure for CBDE whenever possible.

Across the world, choledocholithiasis is presently treated by a two staged approach of Endoscopic Retrograde Cholangio- Pancreatography (ERCP) followed by Laparoscopic Cholecystectomy (LC); in a vast majority of the situations. Modern day literature abounds with comparative outcomes studies between ERCP and Laparoscopic Common Bile Duct Exploration (LCBDE), as therapeutic modalities for Common Bile Duct (CBD) stones. There are strong arguments both in favour and against both these treatment options, in literature. As per literature, the advantage of LCBDE is that it is a single stage procedure, but requires advanced laparoscopic expertise and a choledochoscope in the setup. The advantage of ERCP is that it is a highly standardised procedure. In expert hands and well equipped setups, it rarely ever fails to deliver. However, ERCP is also a highly operator dependant procedure. Also, in the best of hands, sometimes, local factors such as abnormal anatomy, stone morphology can lead to failures or suboptimal results. As per literature, ERCP to extract CBD stones can fail for various reasons such as failed cannulation, previous Billroth II gastrectomy, large CBD stones, large number of CBD stones etc. The failure in retrieving CBD stones by ERCP is an absolute indication for performing CBDE. Here, authors present a case report of a 73-year-old male with failed ERCP (inspite of two attempts) due to a large, solitary but tightly impacted terminal CBD stone. It hopes to convey the message that in similar situations, LCBDE, tactically using some endoscopy accessories, is a sound backup therapeautic option, inspite of non availability of a choledochoscope in the setup. The novelty of this case was that instead of the standard use of choledochoscope to directly visually confirm the completeness of stone clearance during the LCBDE, intraoperative fluoroscopy has been used effectively for the same; by obtaining good quality proximal and distal occlusion cholangiograms at the end of the procedure.

Laparoscopic common bile duct exploration (LCBDE) is increasingly being used to treat choledocholithiasis. However, few studies have examined the treatment of recurrent common bile duct stones (CBDS) in patients with a history of prior biliary surgery. The current research aimed to compare the outcomes of laparoscopic versus open common bile duct exploration in patients with a history of prior biliary surgery.Between March 2010 and August 2019, 162 patients with recurrent CBDS after prior biliary surgery who underwent surgical management in our institution were enrolled in this study. The demographic, intraoperative and postoperative data were retrospectively analysed.Among these 162 patients, 72 underwent laparoscopic approach (LCBDE group), and 90 underwent open surgery (open common bile duct exploration group). The LCBDE group was associated with significantly lower overall complication rate, incision infection rate and blood loss compared to open common bile duct exploration group (all P 0.05). Moreover, the laparoscopic approach significantly reduced the length of postoperative hospital stay (P 0.05). However, the operative time, stone clearance rate, and stone recurrence rate were not significantly different between the two groups (P 0.05). The conversion rate of the laparoscopic approach was 6.9%.LCBDE is superior to open procedure in terms of blood loss, hospital stay, overall complication and incision infection in patients with a history of prior biliary surgery, and it should be considered as a safe and effective treatment if it is performed by an experienced surgeon.

BACKGROUND Laparoscopic common bile duct exploration (LCBDE) can be performed to treat choledocholithiasis at the time of laparoscopic cholecystectomy. The aim of this study was to identify factors that predict the success of LCBDE. MATERIALS AND METHODS A retrospective audit was performed on patients who underwent LCBDE for the management of choledocholithiasis at Northern Health between 2008 and 2018. RESULTS A total of 513 patients were identified with an overall success rate of 90.8%. Most LCBDE were done through a transcystic approach with the remainder through a choledochotomy. When comparing patients with a successful operation to those that were unsuccessful, univariate analysis demonstrated significant differences in preoperative white cell count and number of duct stones found. Age and elevated nonbilirubin liver function tests were found to be significant factors associated with the failure of LCBDE on multivariate analysis. The likelihood of a failed operation in those with multiple stones was observed to be almost halved compared with patients with single stone although this did not reach significance [odds ratio (OR): 0.53, 95% confidence interval (CI): 0.28-1.01, P=0.055]. Multivariate analysis indicated that unsuccessful procedures (OR: 10.13, 95% CI: 4.34-23.65, P

Objective This study was performed to compare the outcomes of laparoscopic common bile duct exploration (LCBDE) after failed endoscopic retrograde cholangiopancreatography (ERCP) versus primary LCBDE for managing cholecystocholedocholithiasis. Methods We retrospectively analyzed data from 59 patients who underwent LCBDE during laparoscopic cholecystectomy (LC) for managing cholecystocholedocholithiasis from January 2013 to August 2019. The patients underwent either primary LCBDE plus LC (Group I) or LCBDE plus LC after failed ERCP (Group II). The demographics, reason for ERCP failure, perioperative details, and postoperative outcomes were evaluated. Results CBD stone removal using preoperative ERCP failed in 31 patients (Group II) because of remaining stones after ERCP (n = 9), failed cannulation (n = 6), failed sedation (n = 6), a periampullary diverticulum (n = 5), previous Billroth II gastrectomy (n = 3), a huge stone (n = 1), and an impacted stone (n = 1). The CBD stone clearance rate was >96% in both groups. The mean operative time, hospital stay, overall complication rate, and open conversion rate were not significantly different between the two groups. Conclusions When extraction of CBD stones by ERCP is likely to be difficult or fail, primary LCBDE is an acceptable alternative treatment for managing cholecystocholedocholithiasis.

Introduction: Both endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct (CBD) exploration (open or laparoscopic) are accepted management techniques for choledocholithiasis.1 L...

Laparoscopic common bile duct exploration (LCBDE) has been recently introduced for management of CBD stone in patients with previous biliary surgery history. The aim of this study was to evaluate the safety and effectiveness of primary closure in patients with previous biliary surgery history compared to T-tube drainage. Eighty patients with previous biliary surgery history including laparoscopic cholecystectomy, open cholecystectomy, or open common bile duct exploration were enrolled in the retrospective study. The patients were divided into 2 groups according to the methods of choledochotomy closure. Group A: patients with primary closure after LCBDE (n = 51); group B: patients with T-tube drainage after LCBDE (n = 29). Group A exhibited a shorter postoperative hospital stay and lower hospitalization expenses compared to group B. There was no significant difference in conversion rate to open surgery, operating time, intraoperative blood loss, bile leakage rate, overall complication rate, and stone recurrence rate between the 2 groups. Biliary stricture was not observed in the 2 groups during the follow-up period. Primary closure following LCBDE is safe and effective for the management of CBD stones in patients with previous biliary surgery history.

Background: The aim of this study is to evaluate complications and costs in patients treated with laparoscopic and open method for common bile duct (CBD) stones. Secondary aim is to compare the eff...

BACKGROUND The purpose of this study was to investigate the effect of a simple laparoscopic common bile duct exploration (LCBDE) simulator and corresponding practicing program on the application of performing LCBDE in a low volume center. METHODS A retrospective review was performed by analyzing data from the electronic medical record for 4118 patients with choledocholithiasis in Changxing County Hospital (Huzhou, Zhejiang, China) between January 2013 and December 2018. From January 2016, we have developed a simple LCBDE-specific simulator and corresponding practicing program in our hospital. The percentage of patients with choledocholithiasis managed by LCBDE before and after the introduction of a simple LCBDE-specific simulator and corresponding practicing program was compared. RESULTS There were 8.9% (367/4118) patients with a diagnosis of choledocholithiasis confirmed by MRCP. Single-stage management with LC+LCBDE was performed in 23.7% (87/367) patients. Among them, 23 cases were performed between January 2013 and December 2015, and 64 cases were performed between January 2016 and December 2018. The introduction of simulator-enhanced practicing program in January 2016 has resulted in an increase in the percentage of performed LCBDE, from 12.9% to 33.9%. In addition, there was an 29.5% reduction in the mean operating time (from 193 min to 136 min) needed for LCBDE with T-tube when compared these two periods. CONCLUSIONS LCBDE simulator can improve the application in a low volume center, and help to increase the utilization of this effective, one stage treatment for choledocholithiasis and reduce the need for costlier ERCP.

This study aimed to describe a novel puncture and discission with a needle (PDN) method facilitating laparoscopic common bile duct exploration (LCBDE). The clinical data of 81 patients with cholelithiasis or choledocholithiasis who underwent LCBDE with PDN between January, 2017 and December, 2017 were retrospectively analyzed. Time for puncture and discission of the bile duct, blood loss, postoperative complications (such as bile leakage, common bile duct [CBD] strictures, and recurrence of choledocholithiasis), and postoperative hospital stay were recorded to evaluate the safety of the method. PDN was performed in all 81 patients with a 100% surgical success rate. Surgery went smoothly. Neither mortality nor complications associated with PDN (portal vein injury or biliary leakage) were observed. The mean time for puncture and discission of the CBD was 2.4 minutes and the maximum blood loss was 100 mL. CBD strictures or recurrence of choledocholithiasis were not noted after 12 to 24 months of follow-up. LCBDE with PDN is a novel method and has the advantages of reliability, convenience, and efficiency without additional costs or complications.

Background Open conversion rates during laparoscopic cholecystectomy vary depending on many factors. Surgeon experience and operative difficulty influence the decision to convert on the grounds of patient safety but occasionally due to technical factors. We aim to evaluate the difficulties leading to conversion, the strategies used to minimise this event and how subspecialisation influenced conversion rates over time. Methods Prospectively collected data from 5738 laparoscopic cholecystectomies performed by a single surgeon over 28 years was analysed. Routine intraoperative cholangiography and common bile duct exploration when indicated are utilised. Patients undergoing conversion, fundus first dissection or subtotal cholecystectomy were identified and the causes and outcomes compared to those in the literature. Results 28 patients underwent conversion to open cholecystectomy (0.49%). Morbidity was relatively high (33%). 16 of the 28 patients (57%) had undergone bile duct exploration. The most common causes of conversion in our series were dense adhesions (9/28, 32%) and impacted bile duct stones (7/28, 25%). 173 patients underwent fundus first cholecystectomy (FFC) (3%) and 6 subtotal cholecystectomy (0.1%). Morbidity was 17.3% for the FFC and no complications were encountered in the subtotal cholecystectomy patients. These salvage techniques have reduced our conversion rate from a potential 3.5% to 0.49%. Conclusion Although open conversion should not be seen as a failure, it carries a high morbidity and should only be performed when other strategies have failed. Subspecialisation and a high emergency case volume together with FFC and subtotal cholecystectomy as salvage strategies can reduce conversion and its morbidity in difficult cholecystectomies.

Background: Primary duct closure (PDC) after laparoscopic common bile duct exploration (LCBDE) has been widely applied for choledocholithiasis. However, there has been controversy over the placement of endoscopic nasobiliary drainage (ENBD) during operation. To date, few studies compare the clinical effect of PDC without and with ENBD. The aim of this study was to assess the safety and efficacy of PDC without ENBD for choledocholithiasis. Methods: From January 2016 to December 2018, a total of 164 patients meeting the inclusion criteria were enrolled and divided into group A (undergone LCBDE + PDC without ENBD, 81 cases) and group B (undergone LCBDE + PDC with ENBD, 83 cases) in this study. The intraoperative conditions and postoperative complications were compared between the 2 groups. Results: In group A, the time of operation, postoperative first flatus, extubation, antibiotics, and discharge were shorter than in group B (t = −17.775, p = 0.000; t = −7.649, p = 0.000; t = −5.807, p = 0.000; t = −9.247, p = 0.000; t = −9.322, p = 0.000, respectively). Furthermore, intraoperative blood loss was less (t = −2.199, p = 0.029) and hospital costs were lower (t = −6.685, p = 0.000). However, there was no significant difference in postoperative complications between the 2 groups (p > 0.05). Conclusions: In patients who meet the screening criteria, PDC without ENBD after LCBDE is safe and effective and worthy of clinical application.

Introduction Primary closure of common bile duct (CBD) after laparoscopic common bile duct exploration (LCBDE) is now becoming the preferred technique for closure of choledochotomy. Primary CBD closure not only circumvents the disadvantages of an external biliary drainage but also adds to the advantage of LCBDE. Here, we describe our experience of primary CBD closure following 355 cases of LCBDE in a single surgical unit at a tertiary care hospital. Materials and methods All patients undergoing LCBDE in a single surgical unit were included in the study. Preoperative and intraoperative parameters including the technique of CBD closure were recorded prospectively. The postoperative recovery, complications, hospital stay, antibiotic usage, and postoperative intervention, if any, were also recorded. Results Three hundred fifty-five LCBDEs were performed from April 2007 to December 2018, and 143 were post-endoscopic retrograde cholangiopancreatography failures. The overall success rate was 91.8%. The mean operative time was 98±26.8 minutes (range, 70 to 250 min). Transient bile leak was seen in 10% of patients and retained stones in 3 patients. Two patients required re-exploration and 2 patients died in the postoperative period. Follow-up ranged from 6 months to 10 years, with a median follow-up of 72 months. No long-term complications such as CBD stricture or recurrent stones were noted. Conclusions Primary closure of CBD after LCBDE is safe and associated with minimal complications and no long-term problems. The routine use of primary CBD closure after LCBDE is recommended based on our experience.

BACKGROUND Primary choledocholithiasis (PC) is a common disease in biliary surgery. The treatment is always challenging due to its high recurrence. A systemic review is undertaken to determine the risk factors for recurrence and provide with the individualized management strategy. METHODS Electronic databases PubMed (Medline), Embase and Cochrane Central Register of Controlled Studies were searched for relevant articles on risk factors for PC recurrence. Its therapeutic intervention was also collected and analysed. RESULTS A total of 36 articles were eligible for inclusion. The recurrent risk factors include abnormalities of biliary anatomy (peripapillary diverticulum), dynamics (choledochal dilation, sharp angulation and stone number), metabolism (advanced age and hypothyroidism) and bacterial infection (Enterobacter and Helicobacter pylori). These factors eventually induce cholestasis and stone formation. At present, there is no guideline and expertise consensus for PC management. The treatment mainly consists of stone retrieval approaches and internal drainage surgeries. The former are minimally invasive methods: endoscopic sphincterotomy (EST), papillary balloon dilation (EPBD) and laparoscopic common bile duct exploration (LCBDE). The latter include choledochoduodenostomy (CDS) and choledochojejunostomy (CJS) with Roux-en-Y reconstruction. By far, the internal drainage surgeries have significantly lower recurrence than stone retrieval approaches. CONCLUSION Abnormal biliary anatomy, dynamics, metabolism and bacterial infection are the risk factors for PC. Both EST/EPBD and LCBDE can be performed as initial treatment. For recurrent PC, CDS is more suitable to the elderly, while Roux-en-Y CJS reserves for young patients or those in good conditions.

Common bile stone disease (CBDS) is frequent and has potentially severe complications, such as acute biliary pancreatitis and cholangitis. Unnecessary and unplanned procedures must be avoided, so before choosing the best treatment of common bile duct lithiasis it is essential to have a proper diagnose. CBDS is currently treated by therapeutic endoscopic retrograde cholangiopancreatography (ERCP) or laparoscopic bile duct exploration (LCBDE). The aim of this article is to present a innovative hybrid technique of common bile duct exploration, on account of one option in those cases where the laparoscopic approach is not resolutive, avoiding the need of conversion to open approach technique. The hybrid technique has the same benefits of open and laparoscopic techniques, but without increasing costs with material and with good resolutivity in complex cases of common bile duct stones. Keywords: Choledocholithiasis; laparoscopic common bile duct exploration; LCBDE; open common bile duct exploration

Background Many options exist for the management of cholelithiasis and secondary choledocholithiasis. Among them, laparoscopic common bile duct exploration (LCBDE) with choledocotomy followed by laparoscopic cholecystectomy has gained popularity. However, efforts should be made to ensure minimally invasive or noninvasive management of the common bile duct (CBD). The purpose of this study was to explore the clinical experience of non-invasive surgical modality, i.e., laparoscopic transcystic dilation of the cystic duct confluence in CBD exploration (LTD-CBDE), including feasibility, safety, adverse events, and incidence. Methods In this retrospective analysis, 68 patients were offered the LTD-CBDE technique from December 2015 to April 2018 based on patient’s own intention. During the surgery, the cystic duct confluence was dilated with separation forceps and/or a columnar dilation balloon. Subsequently, CBD exploration and stone extraction were performed with a choledochoscope. The entrance of the CBD was covered with a cystic duct stump wall and was subjected to primary closure at the end of surgery. Results Forty-nine females and 19 males with cholelithiasis and secondary choledocholithiasis were included. The mean age was 53 years old (18 to 72 year). Of these patients, 62 (91.2%) were successfully treated with the LTD-CBDE technique, and bile leakage was observed in 3 patients (4.4%). The mean operation time was 106 min, and the mean hospital stay was 5.9 days. Among the other 6 patients, 3 were converted to open cholecystectomy due to severe fibrosis, unclear anatomical structure at Calot’s triangle (n = 2) or Mirizze syndrome (n = 1); LCBDE was performed in 3 patients due to cystic duct atresia (n = 2) and low level of flow from the gallbladder duct into the CBD (n = 1). These patients had a smooth postoperative course. In total, 43/68 of the patients presented no radiological evidence of retained CBD stones at the postoperative follow-up (40 patients treated with LTD-CBDE) 1 year later. Conclusions The current work suggests that LTD-CBDE for the management of cholelithiasis and secondary choledocholithiasis is a feasible, safe and effective technique with a low complication rate. LTD-CBDE offers another alternative for surgeons to treat patients in similar scenarios. However, additional randomized, controlled studies are needed to demonstrate its efficacy, safety, and impact on CBD stenosis.

Background: To date, several clinical trials have demonstated that both one-stage laparoscopic cholecystectomy (LC) combined with common bile duct exploration (LC+BDE) with primary closure and one-...

Laparoscopic approaches for the management of Mirizzi syndrome (MS) are controversial and challenging procedures for high conversion rate. This review aims at evaluating their safety and feasibility. We reviewed studies related to the laparoscopic approaches for the management of MS with detailed data of articles from January 2009 to December 2019 found in PubMed. From 63 articles, we reviewed 17 articles detailing laparoscopic approaches for MS. There were 857 patients with MS; 432 of which were identified from 73,842 patients underwent cholecystectomy. Laparoscopic approaches were attempted in 440 patients and were successful in 290. The conversion rate was 34.09%. Various methods including laparoscopic cholecystectomy, laparoscopic subtotal cholecystectomy, laparoscopic common bile duct exploration (LCBDE) and (LTCBDE) were performed. The preoperative diagnosis of MS was made in 338 of 500 patients (67.60%). The mean operating time ranged from 49.7 ± 27.5 min to 270.5 ± 65.5 min, and the mean intraoperative bleeding varied from 21.1 ± 15.9 ml to 162.81 ± 40.83 ml. The mean hospital stay varied from 4.5 ± 3.7 to 7.21 ± 1.61 days. Postoperative complications occurred in 27 patients. Various laparoscopic approaches are safe and feasible for the treatment of MS in the hands of experienced laparoscopic surgeons, especially for type I and II of Csendes classification. Definitive preoperative diagnosis and earlier management are essential.

Background: Despite the effectiveness of laparoscopic common bile duct (CBD) surgery, no case series details the use and advantages of laparoscopic CBD exploration (LCBDE) without use of intraoperative cholangiography (IOC) in endoscopic retrograde cholangiopancreatography (ERCP) failure. Therefore, we present a case series regarding our success with LCBDE in managing CBD stones (CBDSs) using laparoscopic technique without IOC. Materials and Methods: We performed a descriptive retrospective observational study. Patients with CBDSs, alone or along with gallbladder stones, were treated through LCBDE with primary CBD closure after failed ERCP. Results: All patients underwent LCBDE with choledocotomy and primary duct closure. Patients with gallbladder stones underwent laparoscopic cholecystectomy (78%). All procedures were successful, and no conversions occurred. Surgery duration averaged 106 minutes. Intraoperative bleeding averaged 15 cc, and no mortalities occurred. No patients required additional surgery or intensive care unit admission. Hospitalization duration averaged 5 days. Conclusions: Therefore, a laparoscopic approach with primary CBD closure after failed ERCP for complex CBDSs is safe and effective.

IntroductionBiomaterial technology due to its lack of or minimal side effects in tissues has great potential. Traditionally biomaterials used were cobalt-chromium, stainless steel and nitinol alloys. Biomaterials such as magnesium (Mg) and zinc (Zn) have good biocompatibility and consequently can be a potential material for medical implants. To date, the effects of AZ31 alloy stent on cell apoptosis are still unclear. The current investigation was designed to determine the effect of AZ31 alloy stent on necrosis and apoptosis of common bile duct (CBD) epithelial cells.Material and methodsWe experimented with application of different concentrations of AZ31 alloy stent to primary mouse extrahepatic bile epithelial cells (MEBECs) and estimated the effect on apoptosis and necrotic cells. Apoptosis and pro-apoptosis expression were estimated through real-time PCR. For in vivo protocol, we used rabbits, implanted the AZ31 bile stent, and estimated its effect on the CBD. AZ31 (40%) concentration showed an effect on the apoptotic and necrotic cells.ResultsReal-time PCR revealed that AZ31 (40%) concentration increased the apoptotic genes such as NF-κB, caspase-3, Bax and Bax/Bcl-2 ratio as compared to the control group. In the in vivo experiment, AZ31 alloy stents were implanted into the CBD and showed an effect on the alteration the hema¬tological, hepatic and non-hepatic parameters.ConclusionsTo conclude, it can be stated that AZ31 induces apoptosis via alteration in genes including nuclear factor kappa-B (NF-κB), caspase-3, Bax and Bax/Bcl-2 ratio and improved the hematological, hepatic and non-hepatic parameters.

Bouveret syndrome, a specific form of gallstone ileus, is the obstruction of the gastric outlet by a gallstone, which can enter the duodenum through a fistula. While the average age of individuals with Bouveret syndrome is 74 years, our patient was 42 years of age at the time of operation, significantly younger than the average patient afflicted with this condition. In the treatment of our patient’s condition, the operation conducted entailed a partial duodenectomy, gastrojejunostomy, cholecystectomy, common bile duct exploration, extraction of bile duct stones, and insertion of a t-tube in the bile duct. The patient was found to be in healthy condition upon check-up six months after the operation. The outcome of our case suggests that younger Bouveret patients can safely undergo multiple surgical procedures in the treatment of Bouveret syndrome. Our case also suggests that a cholecystectomy and the removal of the obstructing gallstone can both be carried out within one operation, although coupling these two procedures in one operation might be riskier for patients within the normal age range of Bouveret syndrome. We also suggest that fistula repair be carried out for younger Bouveret patients in particular and that the patient be subjected to a CT scan in the diagnosis of Bouveret syndrome when this condition is suspected.

Laparoscopic CBD exploration (LCBDE) for Common bile duct (CBD) stones with laparoscopic cholecystectomy (LC) is an alternative to open CBD exploration, in patients with failed endoscopic retrograde cholangio-pancreatography (ERCP). It is being performed at few centres with adequate surgical expertise. Herein, we present our experience of LCBDE with LC over a period of 10 years.A retrospective analysis of prospectively recorded data of 121 consecutive patients was performed from February 2010 to November 2019, who underwent LC and LCBDE by choledochotomy in a single surgical unit. These included all patients with failed pre-operative ERCP.Out of 121 patients, LCBDE successfully cleared the CBD in 118, and three patients were converted to open surgery. All these patients underwent choledochotomy for adequate exploration of CBD. T-tube closure of CBD was performed in 103 patients and removed after a mean of 14.6 ± 2.4 days. Primary closure was performed in 15 patients. The mean hospital stay post-procedure was 3.4 ± 0.7 days. Complete ductal clearance was achieved in 115 patients, and residual stone fragments reported in three patients were removed by ERCP. None of the patients experienced biliary peritonitis, biliary fistula, pancreatitis or cholangitis. There was no 30-day mortality and no recurrent stones reported with a mean follow-up of 12.4 ± 3.9 months.With adequate surgical expertise, LCBDE is a feasible alternative to open surgery for CBD stones after failed ERCP with early recovery and low morbidity.

Emergent laparoscopic transcystic common bile duct exploration (LTCBDE) has been reported to be on the increase in some institutions, reflecting the growing confidence with the technique. However, no study has focused on the outcomes of LTCBDE in the non-elective setting. The aim of this study is to investigate whether LTCBDE can be performed effectively and safely in the emergency. This is a retrospective study of 500 consecutive patients with choledocholithiasis subjected for LTCBDE at the Hospital Italiano de Buenos Aires from January 2009 to January 2018. Procedures were classified according to the setting as emergent or elective. Demographic data and perioperative parameters were compared between groups. Throughout the period comprised, 500 patients were admitted for choledocholithiasis and gallstones. A single-step treatment combining LTCBDE and laparoscopic cholecystectomy was attempted: 211 (42.2%) were performed electively and the 289 (57.8%) as an emergency. There was no significant difference in the success rate of LTCBDE (93.9% versus 93.8%, p = 0.975) for the two groups. The operative time was slightly longer in the emergency group (122 ± 63 versus 106 ± 53 min, p = 0.002). Postoperative recovery was slower in the emergency group, as reflected by a higher rate of prolonged postoperative stay (21.1% vs 5.7%, p

With the advent of minimally invasive surgery, the limits of surgery have been stretched by questioning the more usual, established 2-stage approach for choledocholithiasis with an initial endoscopic retrograde cholangiography and endoscopic biliary sphincterotomy followed by laparoscopic cholecystectomy in favor of the single-stage laparoscopic common bile duct exploration with laparoscopic cholecystectomy. The aim of this study was to compare the related benefits, difficulties, and outcomes of these 2 methods at a single institution.A retrospective analysis of 128 patients satisfying the inclusion criteria was divided into 2 groups (n = 68 for the group with laparoscopic common bile duct exploration with laparoscopic cholecystectomy and n = 60 for the group with endoscopic retrograde cholangiography/laparoscopic cholecystectomy) between 2014 and 2017. Patient data including age, sex, duration of the operation, intraoperative and postoperative complications, and duration of hospital stay were reviewed.The group with laparoscopic common bile duct exploration with laparoscopic cholecystectomy had 24 men and 44 women (mean age 52 years), and the group with endoscopic retrograde cholangiography/laparoscopic cholecystectomy had 16 men and 44 women (mean age 47 years). Statistically significant results were found in the clearance range (100% in the group with laparoscopic common bile duct exploration with laparoscopic cholecystectomy versus 75% in the group with endoscopic retrograde cholangiography/laparoscopic cholecystectomy), a shorter total duration of hospitalization for the group with laparoscopic common bile duct exploration with laparoscopic cholecystectomy (4.1 days vs 8.4 days) (P.05), but a great incidence of biliary leakage in the group with laparoscopic common bile duct exploration with laparoscopic cholecystectomy. Duration of surgery was not different between the 2 groups.Laparoscopic common bile duct exploration with laparoscopic cholecystectomy is a single-stage procedure that has many advantages over endoscopic retrograde cholangiography/laparoscopic cholecystectomy if appropriate experience and when expertise is available.

Common bile duct (CBD) suturing is a difficult procedure in laparoscopic CBD exploration. We sought to develop a simpler CBD suture technique using running barbed sutures. We retrospectively compared 2 suture techniques for CBD closure after T-tube placement. The barbed group comprised of 46 patients who underwent CBD closure using running barbed sutures, whereas the standard group comprised of 39 patients who received interrupted sutures. Mean CBD suturing time (6.2±0.9 vs. 12.2±1.1 min; P

Purpose. Laparoscopic common bile duct exploration (LCBDE) has been widely used to remove common bile duct (CBD) stones. However, surgery is not considered as the first treatment choice for elderly patients with CBD stones because of the potential risk of postoperative complications. This study aims to evaluate the safety and efficiency of LCBDE for elderly patients. Methods. From April 2011 to October 2016, 265 consecutive patients underwent LCBDE. We performed a retrospective study and divided these patients into 2 groups. The younger group was younger than 70 years old (n = 179), and the elderly group was 70 years old or older (n = 86). We compared patient demographics, clinical characteristics, intraoperative parameters, postoperative complications, and incidence of recurrent stone between the 2 groups. Results. The elderly patients had higher preoperative morbidity of chronic diseases, such as pulmonary diseases, heart diseases, arterial hypertension, and abdominal operation history ( P < .05). There were no significant differences between the 2 groups in terms of operation time, intraoperative blood loss, conversion rate to open surgery, total cost, overall complications, and incidence of recurrent stone ( P > .05). Conclusion. LCBDE can also be carried out as a safe and effective approach to remove CBD stones in elderly patients, although they have higher risk of chronic diseases.

Although laparoscopic common bile duct exploration (LCBDE) has shown many obvious advantages compared with open surgery in the treatment of common bile duct (CBD) stones, it remains unclear regarding risk factors of conversion from LCBDE to open surgery and whether conversion will counteract the advantages of LCBDE. The purpose of this study was to explore risk factors and consequences of conversion from LCBDE to open surgery. A retrospective study was conducted, using a database of 644 patients with LCBDE between 2011 and 2017. Risk factors for conversion to open surgery were determined based on univariable and multivariable analysis. The consequences of conversion to open surgery in LCBDE were analyzed. Conversion was required in 27 (4.2%) of 644 patients undergoing LCBDE. Independent risk factors for conversion were as follows: the max diameter of stones in CBD (odds ratio (OR) 2.234, 95%CI 1.031–4.842; p = 0.042), edema of CBD (OR 12.530, 95%CI 4.633–33.887; p

The best approach for treating common bile duct stones remains a matter of debate. Traditional laparoscopic common bile duct exploration (LCBDE) can cause adverse events such as stenosis of the bile duct. Moreover, with advances in technology and surgical skills, the use of laparoscopic transcystic common bile duct exploration (LTCBDE) is gradually rising. To compare the safety, feasibility, and short-term clinical benefits of LTCBDE and LCBDE through matched cases. Web of science, Cochrane, PubMed, and CNKI were searched systematically to identify studies published between January 2007 and December 2017 that compared LTCBDE and LCBDE without a restriction of languages. This meta-analysis was performed using Review Manager 5.3. Twenty-one studies matched the selection criteria, including 1561 cases of LTCBDE and 1500 cases of LCBDE. There was no obvious difference in stone clearance (OR 1.44, 95% CI 0.84–2.47; P = 0.18). However, LTCBDE had a shorter operative time (MD − 17.72, 95% CI − 19.42 to − 16.02; P

The ideal management of common bile duct (CBD) stones remains controversial, whether with single-stage management using laparoscopic CBD exploration (LCBDE) during laparoscopic cholecystectomy, or with 2-stage management using preoperative or postoperative ERCP. We wished to elucidate the practice patterns within our health system, which includes both large urban referral centers and small rural critical access hospitals.We conducted a retrospective data analysis from our 22-hospital, not-for-profit, integrated healthcare system. All patients with a diagnosis of choledocholithiasis who underwent laparoscopic cholecystectomy (LC) and either ERCP or LCBDE for duct clearance between 2008 and 2013 were included. Demographic data, along with disease-specific characteristics and outcomes, were collected and compared.During the study period, 37,301 patients underwent LC. Of these, 1,961 (5.3%) met inclusion criteria. Single-stage management with LC+LCBDE was performed in 28% of patients, and the remaining 72% underwent 2-stage management with ERCP (73% postoperative ERCP, 27% preoperative). Mean total number of procedures was lowest in the LC+LCBDE group vs the post-cholecystectomy ERCP group vs the preoperative ERCP group (mean 1.4 vs 2.1 vs 2.3; p0.05). Hospital charges were also lower in the LC+LCBDE group vs post-cholecystectomy ERCP vs preoperative ERCP groups ($9,000 vs $10,800 vs $14,200; p0.05). Single-stage vs two-stage management varied greatly between hospitals (from 0% to 93%).Single-stage management of CBD stones resulted in the fewest procedures and lower hospital charges without an increase in complications. Single-stage management (LC+LCBDE) of CBD stones is underused and can offer better value in today's cost-constrained environment.

The laparoscopic approach is considered the standard of care for cholecystectomy. Attempts to minimize incisions with single site and natural orifice approaches have shown promise but also have limitations. Technological advances have facilitated decreased port size, which may have a variety of benefits. The aim of this study was to determine the feasibility of an all 5-mm port approach for patients undergoing both elective and emergency laparoscopic cholecystectomy. A consecutive series of laparoscopic cholecystectomies at three different hospitals using all 5-mm ports was prospectively evaluated. Recorded outcomes included operative findings, procedural difficulties, the need to extend the umbilical incision during extraction, operative time, length of stay and post-operative complications. A total of 101 patients were included and all had a successful cholecystectomy without the need for additional ports. The umbilical incision was extended for gallbladder extraction in 29 (29%) patients. Eight (8%) patients experienced minor post-operative complications and there were no major complications. Cholangiography was performed in 98% of cases and three patients underwent successful common bile duct exploration without requiring additional ports. In a small number of cases, there was difficulty with the quality of the view through the 5-mm laparoscope but this was rectified by removing old or damaged laparoscopes from the circulating stock. This study demonstrates that laparoscopic cholecystectomy using all 5-mm ports is both feasible and safe, and is comparable to published outcomes after conventional laparoscopic cholecystectomy. Further work is needed to determine whether this approach can also improve short- and long-term outcomes.

Background Laparoscopic common bile duct exploration (LCBDE) has emerged as a recommended alternative to endoscopic retrograde cholangiopancreatography (ERCP) for the management of choledocholithiasis. However, its use in the elderly has been limited, and evidence of its safety and efficacy in these patients is yet to be established. This study describes our experience of LCBDE in elderly patients, analysing the safety and efficacy of this technique in comparison to younger patients. Methods All patients undergoing laparoscopic cholecystectomy (LC) with LCBDE for choledocholithiasis in our unit between January 2015 and January 2017 were included. Data pertaining to patient demographics, comorbidities, investigations, operative technique and outcomes were analysed. Patients were divided into 2 groups based on age (Group A:/ = 65 years) for comparative analysis. Results 124 patients (Group A: 65, Group B: 59) were included. Group B were more co-morbid and had a higher ASA grade than Group A. However, there was no significant difference between groups in rates of conversion to open or complications, including bile leak (3.1% vs 5.1%, p = 0.67), retained stone (4.6% vs 1.7%, p = 0.62), or complications according to Clavien-Dindo classification (p = 0.78). Re-intervention rates were also similar between groups (7.7% vs 3.4%, p = 0.44 and 3.1% vs 3.4%, p = 1.0 respectively), as was length of stay. Conclusion Despite higher frequency of comorbidities and ASA grade, LCBDE in elderly patients is safe and effective, and has similar outcomes to younger patients. Therefore elderly patients with choledocholithiasis should be offered LCBDE as an alternative to ERCP., Highlights • Laparoscopic common bile duct exploration in elderly patients is safe despite comorbidities and higher ASA grades than younger patients. • Elderly patients have similar rates of operative success, conversion to open, complications, length of stay and readmission to younger patients. • Laparoscopic common bile duct exploration following intra-operative bile duct imaging without pre-operative imaging is safe and reliable.

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. 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. 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

Laparoscopic common bile duct exploration is an underutilized treatment for choledocholithiasis. We sought to evaluate the impact of a simulation-based mastery-learning curriculum for surgical residents on laparoscopic common bile duct exploration utilization and to compare outcomes for patients treated with laparoscopic common bile duct exploration versus endoscopic retrograde cholangiopancreatography (ERCP).The number of laparoscopic common bile duct explorations performed before and after curriculum implementation was reviewed and outcomes were compared between patients with choledocholithiasis managed with laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography. Based on cost savings from increased utilization of laparoscopic common bile duct exploration, the annual return on investment associated with the curriculum was calculated.Twenty-two residents completed the curriculum. In the pre-curriculum period, an average of 1.7 laparoscopic common bile duct explorations was performed yearly, which increased to 8.4 cases per year after curriculum implementation (P .05). Identified were 155 patients with choledocholithiasis: 31 underwent laparoscopic common bile duct exploration plus laparoscopic cholecystectomy and 124 underwent endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy. The laparoscopic common bile duct exploration and laparoscopic cholecystectomy group had a reduced duration of stay (2.5 ± 1.8 days versus 4.3 ± 2.2 days, P .0001) and costs ($12,987 ± $3,286 versus $15,022 ± $4,613, P = .01) compared with endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy. Rates of readmission and reoperation were equivalent between groups. Cost savings were more than $38,000, resulting in a 3.8 to 1 return on investment from curriculum implementation.A simulation-based mastery-learning curriculum increased institutional utilization of laparoscopic common bile duct exploration and adoption of the curriculum resulted in positive return on investment.

Choledocholithiasis is a rare diagnosis in the infant population with poorly defined optimal management. Endoscopic and operative interventions are both technically challenging. Endoscopic retrograde cholangiopancreatography (ERCP), common bile duct exploration and laparoscopic cholecystectomy are typically safe and successful when performed. However, choledocholithiasis has been reported to spontaneously resolve in up to 60% of cases in neonates and infants. We present five cases of choledocholithiasis in infants and a comprehensive review of the literature. Based on our review and experience, we make a recommendation that clinicians should proceed with a selective approach in the management of this disease based on severity of symptoms, co-morbidities, and the available surgical and endoscopic capabilities of each institution.

There are three choledochotomy closure methods available following laparoscopic common bile duct exploration: T-tube insertion, antegrade stenting, and primary choledochorrhaphy. We reviewed the experience of 12 years at our center searching for the optimal closure technique.We analyzed retrospectively 146 patients that underwent one of the three closure methods from February 2004 to March 2016. Hospital stay, need for readmission, incidence of early and long-term complications, and biliary leakage development and their clinical impact were determined for each technique.Hospital stay was more prolonged, and need for readmission was higher in the T-tube group. Nine patients of the T-tube group (17.3%), 5 patients (8.6%) of the antegrade stenting group, and 1 patient of the primary suture group (2.8%) developed Dindo-Clavien ≥3 complications (P = .076). The incidence of biliary leakage was 3.8%, 8.6%, and 16.7% for the T-tube group, antegrade stenting group, and primary suture group, respectively. There was no grade C biliary fistula in the primary suture group, and all grade B leaks in these patients were only due to prolonged duration. The T-tube removal caused adverse events in 21.1% of the patients, and complications directly related with stents occurred in 9.6%.Antegrade stents or T-tube insertion do not provide any added value for choledochotomy closure but are charged with specific morbidity. On the contrary, despite biliary leaks being more frequent after primary suture, they are of little clinical consequence and may be managed on an outpatient basis.

Background: We present here our experience of laparoscopic hepatopancreaticobiliary (HPB) surgeries at our rural institute and the hurdles we faced overcoming the various challenges. Aims and Objectives: The objectives of this study were to assess the feasibility, successful completion, operative time, conversions/requirement of assistance, duration of hospital stay, and postoperative complications on the HPB procedures performed laparoscopically in our surgical unit; and to help young surgeons for smooth navigation through their laparoscopic career. Materials and Methods: All the patients admitted under our unit over the past 9 years for elective HPB surgeries operated by a single surgeon were included in this study. Results: Total 1304 basic laparoscopic biliary procedures were successfully completed laparoscopically. After getting well versed with the standard procedure, we switched over to difficult cases involving densely adhered gallbladder, frozen Calot's, Mirizzi's syndrome, use of intraoperative cholangiogram, and take down of cholecystoduodenal fistulas. Next step in evolution was doing laparoscopic common bile duct exploration and biliary procedures with decreased number of ports. Five hundred and sixty-eight procedures were advanced HPB surgeries. With time, we also started performing a variety of complex advanced laparoscopic procedures such as cystogastrostomy, hepaticojejunostomy, choledochoduodenostomy, and pancreaticojejunostomy. All these procedures have been discussed with respect to operative duration, conversion rates, blood loss, hospital stay, and complication rates in the initial and later parts of the learning curves and further compared with previous standard large case studies on specific surgeries. Conclusion: Several hurdles are met in a new institute, that too, a rural one. The present discussion will help the budding surgeons to identify their deficiencies and chart a way forward in a systematic scientific manner.