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Background: Subtotal cholecystectomy is advocated in patients with severe inflammation and distorted anatomy preventing safe removal of the entire gallbladder. Not well documented in this surgically complex population is the feasibility of intraoperative imaging and management of common bile duct (CBD) stones. We evaluated these operative maneuvers in our subtotal cholecystectomy patients. Methods: We retrospectively reviewed all cholecystectomy cases from 2014 to 2023 at a single Veterans Affairs (VA) Medical Center using VASQIP (VA Surgical Quality Improvement Program), selecting subtotal cholecystectomy cases for detailed analysis. We reviewed operative reports, imaging and laboratory studies, and clinical notes to understand biliary imaging, stone management, complications, and late outcomes including retained stones (within 6 months), and recurrent stones (beyond 6 months). Results: 419 laparoscopic (n = 406) and open (n = 13) cholecystectomies were performed, including 40 subtotal cholecystectomies (36 laparoscopic, 4 laparoscopic converted to open). Among these 40 patients IOC was attempted in 35 and completed in 26, with successful stone management in 11 (9 common bile duct exploration [CBDE], 2 intraoperative endoscopic retrograde cholangiopancreatography [ERCP]). In follow-up, 3 additional patients had CBD stones managed by ERCP, including 1 with a negative IOC and 2 without IOC. Thus, 14 (35%) of 40 patients had CBD stones. Of note, IOC permitted identification and oversewing or closure of the cystic duct in 32 patients. There were no major bile duct injuries and one cystic duct stump leak (2.5%) that resolved spontaneously. Conclusions: Subtotal cholecystectomy patients had a high incidence of bile duct stones, with most detected and managed intraoperatively with CBDE, making a strong argument for routine IOC and single-stage care. When intraoperative imaging is not possible, postoperative imaging should be considered. Routine imaging, biliary clearance, and cystic duct closure during subtotal cholecystectomy is feasible in most patients with low rates of retained stones and bile leaks. [ABSTRACT FROM AUTHOR]

Two-step therapy, endoscopic retrograde cholangiopancreatography with papillotomy and stone evacuation from common bile duct (CBD), and laparoscopic cholecystectomy (ERCP/LC) is standard treatment of choledocholithiasis and acute cholecystitis in our hospital, Rīga East University Hospital Gaiļezers. The one-step method, LC with intraoperative transcystic balloon dilatation of the papilla Vateri and anterograde evacuation of gallstones to duodenum (BD/LC), has been introduced in our hospital. The aim of this study was to compare two-step and BD/LC methods and report the outcomes from hospital's clinical experience. A retrospective, comparative study was done from 01.2021 to 10.2023. Patients with acute calculous cholecystitis and choledocholithiasis with gallstone diameter in CBD cm, ASA score I-III were included. Gallstone's diameter and number, hospitalisation time, and success rate were analysed. A total of 95 patients were included in our study, of which 46 patients underwent BD/LC and in 49 patients ERCP/LC was used. Median diameter of gallstones in the CBD was 6.1 mm in BD/LC and 6.3 mm in the ERCP/LC group (p = 0.38). Median hospitalisation time for patients with single-step treatment was seven days, and two-step therapy — 14 days (p = 0.001). The complication rate in BD/LS was 4.34% but in ERCP/LC group — 10.2% after ERCP (p = 0.049). The success rate in BD/LC was 95.6% and in ERCP/LC group — 89.6% (p = 0.145). BD/LC is associated with a shorter hospitalisation time, similar success rate and lower complication rate compared with an ERCP/LC. [ABSTRACT FROM AUTHOR]

Abstract Background This study investigated the clinical application of the indocyanine green (ICG) fluorescence navigation technique in bile duct identification during laparoscopic common bile duct exploration (LCBDE) for complex hepatolithiasis. Methods Eighty patients with complex hepatolithiasis were admitted to our department between January 2022 and June 2023 and randomly divided into control and observation groups. The control group underwent conventional LCBDE, while the observation group underwent LCBDE guided by ICG fluorescence. Results Intraoperatively, the observation group had shorter operation and search times for the common bile duct (CBD), as well as reduced intraoperative blood loss and fewer complications, such as conversion to laparotomy and various injuries (gastroduodenal, colon, pancreatic, and vascular) than the control group, with statistical significance (P

Background: This study investigated the clinical application of the indocyanine green (ICG) fluorescence navigation technique in bile duct identification during laparoscopic common bile duct exploration (LCBDE) for complex hepatolithiasis. Methods: Eighty patients with complex hepatolithiasis were admitted to our department between January 2022 and June 2023 and randomly divided into control and observation groups. The control group underwent conventional LCBDE, while the observation group underwent LCBDE guided by ICG fluorescence. Results: Intraoperatively, the observation group had shorter operation and search times for the common bile duct (CBD), as well as reduced intraoperative blood loss and fewer complications, such as conversion to laparotomy and various injuries (gastroduodenal, colon, pancreatic, and vascular) than the control group, with statistical significance (P < 0.05). Postoperatively, the observation group had lower rates of postoperative bile leakage, abdominal infection, postoperative hemorrhage, and residual stone than the control group. Additionally, the observation group demonstrated significantly shorter times for resuming flatus, removal of the abdominal drainage tube, and hospitalization than the control group, with statistical significance (P < 0.05). Conclusion: ICG fluorescence navigation technology effectively visualizes the bile duct, improves its identification rate, shortens the operation time, prevents biliary tract injury, and reduces the occurrence of complications. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic cholecystectomy with common bile duct exploration (LCBDE) is equivalent in safety and efficacy to endoscopic retrograde cholangiopancreatography (ERCP) plus laparoscopic cholecystectomy (LC) while decreasing number of procedures and length of stay (LOS). Despite these advantages LCBDE is infrequently utilized. We hypothesized that formal, simulation-based training in LCBDE would result in increased utilization and improve patient outcomes across participating institutions. Methods: Data was obtained from an on-going multi-center study in which simulator-based transcystic LCBDE training curricula were instituted for attending surgeons and residents. A 2-year retrospective review of LCBDE utilization prior to LCBDE training was compared to utilization up to 2 years after initiation of training. Patient outcomes were analyzed between LCBDE strategy and ERCP strategy groups using χ2, t tests, and Wilcoxon rank tests. Results: A total of 50 attendings and 70 residents trained in LCBDE since November 2020. Initial LCBDE utilization rate ranged from 0.74 to 4.5%, and increased among all institutions after training, ranging from 9.3 to 41.4% of cases. There were 393 choledocholithiasis patients analyzed using LCBDE (N = 129) and ERCP (N = 264) strategies. The LCBDE group had shorter median LOS (3 days vs. 4 days, p < 0.0001). No significant differences in readmission rates between LCBDE and ERCP groups (4.7% vs. 7.2%, p = 0.33), or in post-procedure pancreatitis (0.8% v 0.8%, p > 0.98). In comparison to LCBDE, the ERCP group had higher rates of bile duct injury (0% v 3.8%, p = 0.034) and fluid collections requiring intervention (0.8% v 6.8%, p < 0.009) secondary to cholecystectomy complications. Laparoscopic antegrade balloon sphincteroplasty had the highest technical success rate (87%), followed by choledochoscopic techniques (64%). Conclusion: Simulator-based training in LCBDE results in higher utilization rates, shorter LOS, and comparable safety to ERCP plus cholecystectomy. Therefore, implementation of LCBDE training is strongly recommended to optimize healthcare utilization and management of patients with choledocholithiasis. [ABSTRACT FROM AUTHOR]

Purpose: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical risk calculator is a risk stratification tool to help predict risks of postoperative complications, which is important for informed decision-making. The purpose of this study was to evaluate the accuracy of the calculator in predicting postoperative complications in patients undergoing common bile duct (CBD) exploration. Methods: A retrospective chart review was completed for 305 patients that underwent open and laparoscopic CBD exploration at a single institution from 2010 to 2018. Patient demographics and preoperative risk factors were entered into the calculator, and the predicted complication risks were compared with observed complication rates. Brier score, C-statistic, and Hosmer–Lemeshow regression analysis were used to assess discrimination and calibration. Results: The observed rate exceeded the predicted rate for any complication (35.1% vs. 21%), return to operating room (5.9% vs. 3.6%), death (3.3% vs. 1%), and sepsis (3% vs. 2.4%). The model performed best in predicting serious complication (Brier 0.087, C-statistic 0.818, Hosmer–Lemeshow 0.695), surgical site infection (Brier 0.068, C-statistic 0.670, Hosmer–Lemeshow 0.292), discharge to rehabilitation facility (Brier 0.041, C-statistic 0.907, Hosmer–Lemeshow 0.638), and death (Brier 0.028, C-statistic 0.898, Hosmer–Lemeshow 0.004). In multivariable analysis, there was no statistically significant predicted complication type that affected the type of surgery. Conclusion: The calculator was accurate in predicting serious complication, surgical site infection, discharge to rehabilitation facility, and death. However, the model displayed poor predictive ability in all other complications that were analyzed. [ABSTRACT FROM AUTHOR]

Background: Previous studies have been published evaluating the benefits and drawbacks of clearing the common bile duct of stones using a single-stage approach (LCBDE + LC) versus a two-stage approach (ERCP followed by LC). These studies have demonstrated that a single-stage approach offers similar outcomes and morbidities as a two-stage approach, with the added benefit of a lower cost and shorter length of stays. However, it is significant we understand why LCBDE is not commonly performed currently and also the lapse in surgical trainee exposure and competence in LCBDE. This paper aims to address the lapse in surgical trainee exposure to LCBDE, evaluate the scopes currently available to perform LCBDE, and review current data evaluating the risks and benefits of single-stage versus two-stage approaches to. Methods: We utilized PubMed to analyze all publications related to the various disposable scopes utilized to perform choledochoscopy. We also discuss the need for disposable scopes and how this new market niche is transforming the choledochoscopy space. Results: We analyzed the data related to single-stage and two-stage approach to choledocholithiasis. We noted an overall shorter length of stay and also decreased costs in favor of a single-stage approach. Conclusion: A single-stage LCBDE is the most cost-effective treatment option for choledocholithiasis in patients with choledocholithiasis undergoing a cholecystectomy. In addition, single-stage approach is associated with shorter length of stay. Knowledge of the available choledochoscopes and tools available to surgeons to perform choledochoscopy is significant. The evidence does support the use of disposable choledochoscope from a cost and cross-contamination perspective. Additionally, efforts should be made to incorporate LCBDE into the teaching paradigm of surgical training programs. [ABSTRACT FROM AUTHOR]

Background: Ultrasound-guided laparoscopic common bile duct exploration (LCBDE) is the surgical management of choledocholithiasis. The procedure presents significant benefits to patients but still fails to be generalised because of the complex set of skills it requires. A simulator for ultrasound-guided LCBDE would allow trainee surgeons as well as experienced surgeons who perform this surgery seldomly to practice and gain confidence. Methods: This article presents the development and validation of an easily reproducible hybrid simulator for ultrasound-guided LCBDE which integrates real and virtual components of the task. We first developed a physical model made of silicone. The fabrication technique is replicable and allows quick and easy production of multiple models. We then applied virtual components onto the model to create training for laparoscopic ultrasound examination. Combined with a commercially available lap-trainer and surgical equipment, the model can be used for training the fundamental steps of the surgery through the trans-cystic or trans-choledochal approaches. The simulator was evaluated through face, content, and construct validation. Results: Two novices, eight middle grades, and three experts were recruited to test the simulator. The results of the face validation showed that the surgeons found the model realistic visually and felt realistic when performing the different steps of the surgery. The content validation indicated the usefulness of having a training system to practice the choledochotomy, the choledochoscopy and stone retrieval, and the suturing. The construct validation highlighted the ability of the simulator to differentiate between surgeons with various levels of expertise. Conclusions: The hybrid simulator presented is a low-cost yet realistic model which allows the surgeons to practice the technical skills required for trans-cystic and trans-choledochal ultrasound-guided LCBDE. [ABSTRACT FROM AUTHOR]

Abstract Background Common bile duct exploration (CBDE) is safe and effective for managing choledocholithiasis, but most US general surgeons have limited experience with CBDE and are uncomfortable performing this procedure in practice. Surgical trainee exposure to CBDE is limited, and their learning curve for achieving autonomous, practice-ready performance has not been previously described. This study tests the hypothesis that receipt of one or more prior CBDE operative performance assessments, combined with formative feedback, is associated with greater resident operative performance and autonomy. Methods Resident and attending assessments of resident operative performance and autonomy were obtained for 189 laparoscopic or open CBDEs performed at 28 institutions. Performance and autonomy were graded along validated ordinal scales. Cases in which the resident had one or more prior CBDE case evaluations (n = 48) were compared with cases in which the resident had no prior evaluations (n = 141). Results Compared with cases in which the resident had no prior CBDE case evaluations, cases with a prior evaluation had greater proportions of practice-ready or exceptional performance ratings according to both residents (27% vs. 11%, p = .009) and attendings (58% vs. 19%, p

Background: Common bile duct (CBD) stones associated with cholecystitis can be treated by single-stage CBD exploration at the time of cholecystectomy or a two-stage approach with endoscopic stone extraction before or after cholecystectomy. The ideal management remains a matter of debate. The aim of this study is to analyze our outcomes with transcystic laparoscopic common bile duct exploration (LCBDE). Material and Methods: A retrospective review of patients who underwent transcystic LCBDE between 2015 and 2019 was performed. Results: A total of 106 patients underwent transcystic LCBDE over 5 years. We performed 1192 laparoscopic cholecystectomies with cholangiograms from March 2015 to December 2019. Fifteen patients had a preoperative endoscopic retrograde cholangiopancreatography (ERCP) for CBD stones seen on magnetic resonance cholangiopancreatography that during laparoscopic cholecystectomy with intraoperative cholangiogram (IOC), there were stones and/or sludge found in the CBD, which required clearance through a transcystic approach. Of the 91 patients who did not have a preoperative ERCP, clearance of the CBD was successful through a transcystic approach in 78 patients (86%). In the 13 patients that intraoperative clearance was not achieved (n = 13, 14%), a postoperative ERCP was performed. A total of 28 patients underwent either pre- or postoperative ERCP (n = 28, 26%). Choledochotomy was not performed in any of the patients. The mean operative time was 127 minutes (127 ± 48). The mean hospital length of stay (LOS) was 4 days (3.9 ± 2.8) with a median LOS of 3 days. Complications observed include wound infection (n = 2, 2%), pancreatitis after ERCP (n = 1, 1%), pneumonia (n = 1, 1%), and right hepatic duct injury (n = 1, 1%). Conclusion: Transcystic LCBDE is an effective and safe option for treatment of CBD stones. While a transcystic approach does not guarantee clearance of the CBD, it avoids the morbidity associated with a choledochotomy and can often prevent patients from having to undergo an additional procedure. [ABSTRACT FROM AUTHOR]

Background: Single-stage laparoscopic common bile duct exploration (LCBDE) with cholecystectomy has superior outcomes over two-stage endoscopic retrograde cholangiopancreatogram with interval cholecystectomy. With decreasing trend of LCBDE, this study aims to summarize the literature on learning curve (LC) in LCBDE. Materials and Methods: PubMed, Embase, Scopus, and the Cochrane Library were systematically searched for articles from inception to June 3, 2022 (PROSPERO Ref No: CRD42022328451). Basic clinical demographics were collected. Poisson means (95% confidence interval [95% CI]) was used to determine the number of cases required to surmount the LC (NLC). Results: Eight articles (n = 2071 patients) reported LC outcomes in LCBDE with mean study period of 5.9 ± 2.8 years. Majority of studies (62.5%) used arbitrary methods of LC analysis. Most common outcomes reported were complications (any or major) (75%), open conversion (75%), length of stay (62.5%), and operating time (50%). Mean CBD diameter was 11.3 ± 4.8 mm (n = 1122 patients). Incidence of acute cholecystitis, acute cholangitis, and acute pancreatitis were 13.9% (n = 232/1668), 7.8% (n = 128/1629), and 13.7% (n = 229/1668), respectively. Pooled analysis of all the included studies showed NLC of 78.8 cases (95% CI: 71.9–86.3). Studies that used cumulative sum control chart analysis, nonarbitrary methods, and arbitrary-based LC had NLC of 152.0 (95% CI: 135.4–170.1), 108.0 (95% CI: 96.6–120.4), and 49.7 (95% CI: 42.0–58.3) cases, respectively. NLC was 37.0 cases (95% CI: 29.1–46.5) for single surgeon LC, and 99.8 cases (95% CI: 90.2–110.0) for institutional LC. Conclusion: Studies reporting NLC in LCBDE are heterogeneous. Further studies should use nonarbitrary methods of analysis for patient-reported outcome measures and procedure-specific morbidity. [ABSTRACT FROM AUTHOR]

Background: Common bile duct exploration (CBDE) is safe and effective for managing choledocholithiasis, but most US general surgeons have limited experience with CBDE and are uncomfortable performing this procedure in practice. Surgical trainee exposure to CBDE is limited, and their learning curve for achieving autonomous, practice-ready performance has not been previously described. This study tests the hypothesis that receipt of one or more prior CBDE operative performance assessments, combined with formative feedback, is associated with greater resident operative performance and autonomy. Methods: Resident and attending assessments of resident operative performance and autonomy were obtained for 189 laparoscopic or open CBDEs performed at 28 institutions. Performance and autonomy were graded along validated ordinal scales. Cases in which the resident had one or more prior CBDE case evaluations (n = 48) were compared with cases in which the resident had no prior evaluations (n = 141). Results: Compared with cases in which the resident had no prior CBDE case evaluations, cases with a prior evaluation had greater proportions of practice-ready or exceptional performance ratings according to both residents (27% vs. 11%, p =.009) and attendings (58% vs. 19%, p <.001) and had greater proportions of passive help or supervision only autonomy ratings according to both residents (17% vs. 4%, p =.009) and attendings (69% vs. 32%, p <.01). Conclusions: Residents with at least one prior CBDE evaluation and formative feedback demonstrated better operative performance and received greater autonomy than residents without prior evaluations, underscoring the propensity of feedback to help residents achieve autonomous, practice-ready performance for rare operations. [ABSTRACT FROM AUTHOR]

Introduction: Concomitant gallstones and common bile duct (CBD) stones is a common problem, and there is still no consensus on the best approach in the management. Options include preoperative endoscopic retrograde cholangiopancreatography (ERCP), Laparoscopic cholecystectomy (LC) with CBD exploration, and LC with postoperative ERCP. Each option has its own limitations and complications. In this article, we assessed the feasibility of laparoscopic surgical clearance of the CBD after a failed ERCP, reasons for failure of endoscopic clearance in our cohort. We will discuss the management options after ERCP failure, the challenges, and the outcomes. Materials and Methods: We retrospectively reviewed all the cases of laparoscopic common bile duct exploration (LCBDE) performed in our hospital between April 2006 and January 2019. Two hundred cases were performed, 178 cases as a primary procedure while 22 were performed as a secondary procedure after failed ERCP. We have previously published data on the case series (PMID 33140155) and here explored the cases performed after failed ERCP as a secondary procedure. We analyzed demographics of patients, preoperative investigations, ERCP trials, and reasons for ERCP failure, operative approach, duration of operation, conversion rate, complications, and outcomes. Results: Twenty-two patients underwent a laparoscopic CBD clearance after failed ERCP. Sixteen of these were in the first 5 years of the study. Multiple attempts of ERCP were made in 7 patients (31.8%) and a single attempt in 15 patients. In 8 patients (32%), the duct was not accessible (failed cannulation) due to a variety of reasons. Nine patients had impacted stones larger than 1 cm, 4 patients had Mirrizi syndrome with concomitant large CBD stones, and 1 patient failed endoscopic clearance because of the large number of stones in the CBD. CBD clearance was successful in 19 patients (88%), 8 were completed by a transcystic approach and 14 by a transcholedochal approach. Postoperative length of stay was 12 (+10) days. One patient had an unplanned readmission within 30 days. One patient required reoperation for bleeding. Three patients developed recurrent stones and 1 developed a subsequent stricture. No mortalities were recorded. Conclusion: LCBDE is feasible and appears safe as a secondary procedure after failed ERCP. The new technologies and the advancement of surgical techniques will continue to improve success and reduce morbidity. [ABSTRACT FROM AUTHOR]

In adults, upfront intraoperative cholangiogram with laparoscopic common bile duct exploration (LCBDE) is well accepted for management of choledocholithiasis. Despite recent evidence supporting LCBDE utility in children, there has been hesitation to adopt this surgery first (SF) approach over ERCP first (EF) due to perceived technical challenges. We compared rates of successful stone clearance during LCBDE between adult and pediatric patients to evaluate if pediatric surgeons could anticipate similar rates of successful clearance. A multicenter, retrospective review of pediatric (<18 years) and adult patients with choledocholithiasis managed from 2018 to 2024 was performed. Demographic and clinical data were obtained. Rate of successful duct clearance with LCBDE was compared. Surgical and endoscopic complications (infections, bleeding, pancreatitis, bile leak) were also compared. 724 patients, 333 (45.9%) pediatric and 391 (54.0%) adults, were included. The median age of pediatric vs adult patients was 15.2 years [13.1, 16.6] vs 55.5 years [34.1, 70.5], respectively. Of these, 201 (60.4%) pediatric vs 169 (43.2%) adult patients underwent SF, p < 0.001. LCBDE was attempted in 84 (41.7%) pediatric vs 140 (82.8%) adults, p = 0.002. LCBDE success was higher in pediatric vs adult patients (82.1% vs 71.4%, p = 0.004). Complications rates were similar however, pediatric patients who underwent EF had higher endoscopic complications (9.1% vs 3.6%, p = 0.03). LCBDE is highly successful in children vs adults with no increased surgical complications. This data, coupled with the limited ERCP access for children, supports that LCBDE is an equally effective tool for managing choledocholithiasis in children as is accepted in adults. Level III. [ABSTRACT FROM AUTHOR]

Common bile duct drainage (CBDD) following operative common bile duct exploration (CBDE) is routinely performed. Primary choledochotomy closure with trans-sphinteric endobiliary stent (EBS) is a popular technique. A 72-year-old woman presented with abdominal pain, peritonism, and sepsis a month after an elective right hemicolectomy with concurrent cholecystectomy and CBDE with EBS placement. Radiological investigations implied a detrimental consequence from migrated EBS. Surgical exploration revealed the cause to be ileal perforation by the EBS. She had a resection of the aggravated bowel segment and a double-barreled stoma was matured from the resected ends. The stoma was reversed 6 weeks after the laparotomy and the patient is currently under regular surveillance for colon cancer. Migration of EBS precipitating enteric perforation are uncommon, recognised complications. Natural, congenital, and acquired luminal and mural causes have been documented. Primary choledochotomy closure without CBDD, alternative EBS which are smaller or softer, and the utilization of T-Tube CBDD are valid options when treating patients with recognised increased risk of EBS-related bowel perforation. [ABSTRACT FROM AUTHOR]

In the era of minimally invasive surgery, laparoscopic common bile duct (CBD) exploration is the best choice for addressing different difficult CBD pathologies. In the current study, we have performed laparoscopy in twelve cases (five men and seven women) with failed endoscopic retrograde cholangiopancreatography (ERCP) for CBD calculi (n = 9), a retained stent (n = 1), and CBD injuries (n = 2). The mean age of patients was 46.3 ± 8.9 years. Transcystic or transductal approach was used. In seven cases that underwent rendezvous procedure, two cases required Fogarty balloon trawl. Ureteroscopic guided stent removal was effective in one case. In the absence of choledocoscope, ureteroscope with laser lithotripsy was used in two cases of CBD calculi. Laparoscopy CBD exploration with impacted calculi extraction was effective in two cases of CBD calculi. The mean operation time was 100.3 ± 17.4 min. The pain score was 2.4 ± 0.5. The mean hospital stay was 2.7 ± 0.9 days. T-tube was not used in any of our cases. All of our cases CBD rent closed over the stent. Intraoperative or postoperative cholangiogram was not done in any of our cases. Complete CBD clearance was achieved in all of our cases. Length of stay and pain score were minimal with no postoperative complications. Even in failed ERCP cases, the first laparoscopic approach should be rendezvous procedure with the help of balloon trawl and ureteroscope which can avoid T-tube insertion and also intraoperative cholangiogram. [ABSTRACT FROM AUTHOR]

Background: In recent years, complicated biliary tract diseases are increasingly diagnosed in children. Laparoscopic exploration of the common bile duct (LCBDE) followed by laparoscopic cholecystectomy has gained popularity in children. The aim of this study was to investigate the outcomes of LCBDE in children and compare them with the treatment outcomes of previously used endoscopic retrograde cholangiopancreatography (ERCP). Methods: From January 2000 to January 2022, a total of 84 children (78.5% female) underwent laparoscopic cholecystectomy with a median follow-up of 11.4 (IQR 8, 14) years. Of these, 6 children underwent laparoscopic cholecystectomy (LC) + ERCP and 14 children underwent LCBDE for choledochiothiasis. The primary end point of the study was the success of treatment in terms of the incidence of complications, recurrence rate, and rate of reoperation. Secondary endpoints were stone characteristics, presenting symptoms, duration of surgery, and length of hospital stay. Results: The majority of patients were female in both groups (83.5% vs. 85.7%), mostly overweight with a median BMI of 27.9 kg/m2 and 27.4 kg/m2, respectively. Obstructive jaundice, colicky pain, acute pancreatitis, and obstruction of the papilla were the most common symptoms in both groups. The majority of patients (68%) had one stone, whereas two or more stones were found in 32% of patients. The median diameter of the common bile duct was 9 mm in both groups. The procedure was successfully completed in all patients in the ERCP group. In the group of patients treated with LCBDE, endoscopic extraction of the stone with a Dormia basket was successfully performed in ten patients (71.4%), while in the remaining four patients (28.6%) the stones were fragmented with a laser because extraction with the Dormia basket was not possible. The median operative time was 79 min in the LCBDE group (IQR 68, 98), while it was slightly longer in the ERCP group, 85 min (IQR 74, 105) (p = 0.125). The length of hospital stay was significantly shorter in the LCBDE group (2 vs. 4 days, p = 0.011). No complications occurred in the LCBDE group, while two (40%) complications occurred in the ERCP group: pancreatitis and cholangitis (p = 0.078). During the follow-up period, no conversions, papillotomies, or recurrences were recorded in either group. Conclusions: Exploration of the common bile duct and removal of stones by LCBDE is safe and feasible in pediatric patients for the treatment of choledocholithiasis. Through this procedure, choledocholithiasis and cholelithiasis can be treated in a single procedure without papillotomy or fluoroscopy. Compared with LC + ERCP, LCBDE is associated with a shorter hospital stay. The incidence of complications was rather low but not statistically significant. [ABSTRACT FROM AUTHOR]

Background: Radiation exposure (RE) causes dose-dependent deleterious effects, and efforts should be made to decrease patient exposure to ionizing radiation. Patients with choledocholithiasis are commonly exposed to ionizing radiation as fluoroscopy-guided interventions including minimally invasive common bile duct (CBD) exploration (MICBDE) and endoscopic retrograde cholangiopancreatography (ERCP) are the preferred treatment modalities for CBD stone clearance. However, RE and fluoroscopy times (FTs) have not been compared between these 2 treatment modalities. Thus, this study aimed to compare FT and RE between MICBDE and ERCP in patients with choledocholithiasis., Methods: This is a retrospective analysis of a prospectively maintained database of a single surgeon performing MICBDE at an academic referral center between May 2021 and June 2023 compared with a retrospective analysis of all ERCPs performed between January 2020 and February 2021. Patient demographics, procedural details, fluoroscopic details, and postoperative outcomes were compared between the MICBDE and ERCP. The study was conducted as a single institution academic referral center located in the American Southwest. A total of 109 patients with choledocholithiasis were divided into 2 groups. A total of 53 (48.62%) patients underwent ERCP, and 56 (51.38%) patients underwent MICBDE. Inclusion criterion was all patients presenting with choledocholithiasis and subsequently undergoing ERCP or MICBDE. Patients who underwent ERCP for non-choledocholithiasis-related reasons were excluded. Primary outcomes include FT measured in minutes and RE measured in milligray (mGy). Secondary outcomes were successful clearance of the CBD, complications, procedural time, and reinterventions., Results: A significant difference (P < .001) between FTs was identified between ERCP (3.1 min) and MICBDE (1.54 min). Median RE doses between the ERCP group (38 mGy) and the MICBDE group (38.41 mGy) were not statistically different (P = .88). Technical success of CBD clearance was similar in both groups (91% in the MICBDE group vs 93% in ERCP group; P = .711)., Conclusion: Advantages of MICBDE over ERCP include the treatment of choledocholithiasis at the time of cholecystectomy, which reduces the risk of additional anesthesia episodes and introduces the potential for shorter hospital length of stay. This study showed that MICDBE had lower FT than had ERCP, and comparable RE. Given the advantages of MICBDE, it should be strongly considered at the time of laparoscopic cholecystectomy., (Copyright © 2024 Society for Surgery of the Alimentary Tract. Published by Elsevier Inc. All rights reserved.)

Background: There remain controversies regarding the surgical treatment of extrahepatic bile duct stones (EHBDSs) in clinical practice., Aim: To explore the curative effect of laparoscopic cholecystectomy (LC) plus common bile duct exploration (CBDE) for the surgical treatment of EHBDSs and to analyze the risk factors that affect postoperative stone recurrence., Methods: Eighty-two patients with EHBDSs admitted between March 2017 and March 2023 were selected. Among them, patients treated with open choledocholithotomy plus LC or open cholecystectomy (OC) were set as the control group ( n = 40), and those treated with LC plus CBDE served as the observation group ( n = 42). The surgical outcomes of the two groups were compared, the surgical complications and Gastrointestinal Quality of Life Index (GIQLI) scores were counted, and the one-year prognostic recurrence was recorded. Independent factors for postoperative recurrence were determined using univariate and multivariate analyses., Results: The two groups were comparable in the stone residual rate ( P > 0.05). The operation time ( P < 0.05), intraoperative bleeding ( P < 0.05), and total complication rate ( P = 0.005) were lower in the observation group than in the control group. The observation group exhibited a marked increase in the GIQLI score, which was higher than the control group ( P < 0.05). A lower one-year recurrence rate was determined in the observation group vs the control group ( P = 0.027). Sphincter of Oddi dysfunction [odds ratio (OR) = 5.712, P = 0.007] and the treatment scheme of open choledocholithotomy plus LC or OC (OR = 6.771, P = 0.008) were the independent risk factors for one-year recurrence in patients after surgery., Conclusion: LC plus CBDE for patients with EHBDSs can reduce stone residuals, intraoperative bleeding, complications, and postoperative recurrence., Competing Interests: Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article., (©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.)

Objectives: The challenges posed by laparoscopic cholecystectomy (LC) in obese patients and the methods of overcoming them have been addressed by many studies. However, no objective tool of reporting operative difficulty was used to adjust the outcomes and compare studies. The aim of this study was to establish whether obesity adds to the difficulty of LC and laparoscopic common bile duct exploration (LCBDE) and affects their outcomes on a specialist biliary unit with a high emergency workload. Methods: A prospectively maintained database of 4699 LCs and LCBDEs performed over 19 years was analysed. Data of patients with body mass index (BMI) ≥ 35, defined as grossly obese, was extracted and compared to a control group. Results: A total of 683 patients (14.5%) had a mean BMI of 39.9 (35–63), of which 63.4% met the definition of morbidly obese. They had significantly more females and significantly higher ASA II classifications. They had equal proportions of emergency admissions, similar incidence of operative difficulty grades 4 or 5 and no open conversions and were less likely to undergo LCBDE than non-obese patients. There were no significant differences in median operative times, morbidity, readmission or mortality rates. Conclusions: This study, the first to classify gall stone surgery in obese patients according to operative difficulty grading, showed no difference in complexity when compared to the non-obese. Refining access and closure techniques is key to avoiding difficulties. Index admission surgery for biliary emergencies prevents multiple admissions with potential complications and should not be denied due to obesity. [ABSTRACT FROM AUTHOR]

Background: An estimated 8–15% of patients undergoing cholecystectomy have concomitant common bile duct stones. In this 14-year study, we utilize data of patients at a high-volume tertiary care academic center and compare the clinical outcomes of patients undergoing intraoperative cholangiography (IOC) and endoscopic retrograde pancreatography (ERCP). Methods: The charts of 1715 patients in the institutional NSQIP database who underwent cholecystectomy between October 1st, 2005 and September 30th, 2019 were retrospectively reviewed. Patients who underwent cholecystectomy in relation to a malignancy diagnosis or who underwent an ERCP in a different index hospitalization were excluded. Main outcomes included hospital length of stay (LOS), post-operative morbidity, and rate of readmissions. Results: Of the 1409 patients included in the final analysis, 185 patients underwent ERCP, while 95 patients underwent IOC. Use of IOC compared to preoperative ERCP resulted in a shorter LOS (2.6 vs. 5.3 days, p < 0.001), lower rate of readmission (1.1% vs. 6.5%, p = 0.040), and similar rates of post-operative complications. Mean operative time increased by only 15 min in the IOC compared to the ERCP group (129 vs.114 min, p = 0.047). Additional variables that increased LOS on multivariable logistic regression included age, ASA classification, post-operative complications, and increased number of preoperative tests. Conclusions: This study demonstrates that use of IOC during cholecystectomy results in shorter LOS and fewer readmissions compared to ERCP. Future studies comparing these two approaches should focus on patient randomization, a cost-effectiveness analysis, and identifying barriers to implementation of a one-stage approach in the management of suspected choledocholithiasis. [ABSTRACT FROM AUTHOR]

Objective To compare the clinical effects on elderly patients suffered from gallbladder stones associated with choledocholithiasis between the group of laparoscopic cholecystectomy(LC) with common bile duct exploration (LCBDE) using three scopys including laparoscopy, cholangioscopy and duodenoscopy and the group of endoscopic sphincterotomy(EST) with LC. Methods Sixty elderly patients more than 65 years with stones in gallbladder and common bile duct had common bile duct diameter 10 mm and more in our hospital between March 2018 and June 2019 and were analyzed retrospectively. Thirty-five cases had LC and LCBDE with primary duct closure combined with biliary stent. Twenty-five cases were treated EST with LC. Clinical effects were compared between two groups. Results There was no significant difference in postoperative hospital stay, pancreatitis, biliary bleeding, pulmonary infection and stone recurrence, biliary tract infection between two groups. However, the differences were significant in operative time, hospital cost and postoperative hyperamylasemia between two groups. Conclusions The stones in gallbladder and common bile duct in elderly patients could be treated by LC, LCBDE and primary duct closure combined with biliary stent, which had better clinical effects when compared to EST and LC.

Background: Recurrence after common bile duct stone (CBDS) clearance is the major long-term drawback of their management. Its prevalence is significant, and it occurs after all primary therapeutic alternatives. The aim of this study was to determine the predictive factors associated with stone recurrence after surgical common bile duct exploration (CBDE). Methods: A retrospective cohort study based on patients undergoing CBDE between 2000 and 2018 was conducted. Uni- and multivariate hierarchical regression analyses were performed to assess the independent predictive factors associated with recurrent CBDS in patients with initially successful surgery. Results: A total of 365 patients underwent successful surgical procedures. After a median follow-up of 43.2 (IQR 84) months, 31 (8.4%) patients were diagnosed with CBD stone recurrence. The median time to recurrence was 30.3 (IQR 38) months. The only variable associated with CBDS recurrence was preoperative endoscopic sphincterotomy (HR 2.436, 95% CI: 1.031–5.751, P = 0.042)). Conclusion: Patients who undergo preoperative endoscopic sphincterotomy and then cholecystectomy with successful common bile duct clearance may be at increased risk for recurrent stone disease compared to those who go straight to surgery. [ABSTRACT FROM AUTHOR]

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Abstract Introduction The aim of this study was to assess and evaluate the feasibility of using the Ambu aScope3 (aScope) for common bile duct (CBD) explorations, stone detection and extraction, as well as to assess feasibility of its use through the laparoscopic ports in a low‐volume centre. Methods This is a dual centre prospective study, conducted between February 2015 and August 2019, of patients undergoing laparoscopic cholecystectomy and common bile duct exploration. Ethical approval was obtained from the North West ‐ Greater Manchester South Research Ethics Committee. All patients were counselled on the use of the aScope in clinic, prior to surgery. The Primary endpoints were the ability of the aScope to identify CBD stones, perform a cholangiogram through the available channel, retrieve the stones using a Dormia basket and to visualise second generation biliary radicles satisfactorily. The secondary endpoint was the use of the aScope, via a laparoscopic port without a gas leak. The data collected included patient demographics, need for a CBD exploration, intraoperative confirmation of CBD stones and their safe extraction using an aScope. Results A total of nine patients were recruited. The aScope provided satisfactory views in eight of nine patients and enabled the safe extraction of CBD stones in six of nine cases. One patient had a bile leak, and another had a transected CBD prior to the use of the aScope. Conclusion We found that the aScope is a safe, feasible alternative to a choledochoscope, and in a low‐volume centre, it provides a financially viable option.

Background: Choledocholithiasis is a common complication of cholelithiasis, occurring in up to 18% of patients. Multiple treatments are often performed during the course of the management of choledocholithiasis, sometimes without success. Our study was performed identify the factors predictive of the success of treatment with retrograde endoscopic cholangiopancreatography (ERCP). Methods: This was a retrospective, case–control study that used data from a biliary disease database at Hospital de Clínicas de Porto Alegre (HCPA). Demographic, clinical, radiological and procedure-related variables were compared between patients with successful biliary clearance after one ERCP procedure (Group 1) and those with unsuccessful biliary clearance after one ERCP procedure (Group 2). Results: Three hundred twenty patients were included in Group 1, while 254 were included in Group 2. Multivariate analysis showed that older age, previous biliary exploration, elevated serum total bilirubin, choledocholithiasis above the level of the confluence of the hepatic ducts, stones retained in the cystic duct or Mirizzi syndrome, dilatation of the bile duct diagnosed during ERCP, and the need for suprapapillary opening were independently associated with the failure of the first ERCP to achieve bile duct clearance. The performance of imaging at the same institution prior to the procedure and the retention of stones in the duodenal papilla were associated with the success of endoscopic treatment. Conclusions: The variables identified in this study, when considered in conjunction with the results of previously published studies, can be used to guide the choice of therapeutic methods for patients with choledocholithiasis in the future, given the significant difference in outcomes between the two groups. In the future, a prospective study should be performed to determine whether the same factors are predictive of the success of other methods of treatment (surgical or percutaneous). [ABSTRACT FROM AUTHOR]

Abstract 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.

Objective To compare two approaches of single-stage of treating concomitant gallbladder stones and common bile duct stones. Laparoscopic cholecystectomy (LC) was performed with endoscopic retrograde cholangiography (ERCP) as ERCP group and LC combined with laparoscopic common bile duct exploration (LCBDE) as LCBDE group. Intraoperative ERCP was compared with LCBDE. Methods Retrospective analysis was performed for 189 patients with concomitant gallbladder stones and common bile duct stones in our hospital from January 2017 to December 2018. A total of 111 cases were in ERCP group using LC with ERCP and 78 cases in LCBDE group using LC with LCBDE. The efficacy, safety and economy of two approaches were investigated. Results No statistical significance was present between two groups in gender, age, BMI, ASA grade, and preoperative examination (P>0.05). Significant difference was not found in stone clearance rate and postoperative complications(P>0.05). The cases in LCBDE group had wider indication with more patients of gastric surgery history and larger stones. The cases in ERCP group had less hospital days (6.79±2.78 d vs. 13.18±5.43 d, P

Background: Choledocholithiasis in children is commonly managed with an "endoscopy-first" (EF) strategy (endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC)). Because ERCP availability is often limited at the end of the week (EoW), we hypothesized that a "surgery-first" (SF) approach (LC with intraoperative cholangiogram (IOC) ± transcystic laparoscopic common bile exploration (LCBDE)) would decrease length of stay (LOS) and time to definitive intervention (TTDI)., Methods: A multicenter, retrospective cohort study was conducted on pediatric patients from 2018 to 2023 with suspected choledocholithiasis. Work week (WW) presentation was defined as admission between Monday to Thursday. TTDI was defined as time to LC or postoperative ERCP (if required)., Results: Among seven hospitals, there were 354 pediatric patients; 217 (61%) managed with SF (125 WW, 92 EoW) and 137 (39%) managed with EF (74 WW, 63 EoW). SF groups had a shorter LOS for both WW and EoW presentation (60.2 h and 58.3 h vs 88.5 h and 93.6 h respectively; p < 0.05). TTDI decreased in SF (26.4 h and 28.9 h vs 61.4 h and 72.8 h; p < 0.05). All EF patients underwent at least two anesthetics (preoperative ERCP followed by LC) while the majority (79%) of the SF group had only one procedure (LC + IOC ± LCBDE)., Conclusion: Children who present with choledocholithiasis at EoW have a longer LOS and TTDI. These findings are amplified when children enter an EF pathway. A surgery-first approach results in fewer procedures, decreased TTDI, and shorter LOS, regardless of the time of presentation., Level of Evidence: Level III., Competing Interests: Conflicts of interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The management of choledocholithiasis evolves with diagnostic imaging and therapeutic technology, facilitating a laparoscopic approach. We review our first 200 cases of laparoscopic exploration of the common bile duct, highlighting challenges and lessons learnt.Methods: We retrospectively studied the first 200 cases of laparoscopic cholecystectomy with common bile duct exploration between 2006 and 2019. The database contains demographics, clinicopathological characteristics, diagnostic modalities, operative techniques, duration and outcomes.Results: We compared two approaches: transcystic vs. transcholedochal in our 200 cases. Choledocholithiasis was suspected preoperatively in 163 patients. 21 cases found no stones. Of the remainder, 111/179 cases were completed via the transcystic route and the remaining were completed transcholedochally (68/179); 25% of the transcholedochal cases were converted from a transcystic approach. CBD diameter for transcystic route was 8.2 vs. 11.0 mm for transcholedochal. Total clearance rate was 84%. Retained or recurrent stones were noted in 7 patients. Length of stay was 5.8 days, 3.5 days in the transcystic route vs. 9.4 days after transcholedochal clearance. Eight patients required re-operation for bleeding or bile leak. No mortalities were recorded in this cohort, but 2 cases (1%) developed a subsequent CBD stricture.Conclusion: Concomitant laparoscopic common bile duct clearance with cholecystectomy is feasible, safe and effective in a district general hospital, despite constraints of time and resources. The transcystic route has a lower complication rate and shorter hospital stay, and hence our preference of this route for all cases. Advancements in stone management technology will allow wider adoption of this technique, benefitting more patients. [ABSTRACT FROM AUTHOR]

Ascaris lumbricoides is an intestinal parasite, more common habitant of the small intestine, particularly in the jejunum. It can produce a variety of presentations starting from anemia, gastrointestinal bleeding, intestinal obstruction, perforations, intussusception, and rarely obstructive jaundice. Obstructive jaundice is mainly due to proximal migration of the parasite into the biliary tree and causing an obstruction. It is the most common following biliary procedure. Here, we report the case of obstructive jaundice and cholangitis due to biliary ascariasis in a patient without any prior biliary procedure. Prompt intervention is needed in those cases of ascariasis with biliary sepsis. The patient has been managed by emergency cholecystectomy with common bile duct exploration and T-tube insertion.

Background: In recent years, complicated biliary tract diseases are increasingly diagnosed in children. Laparoscopic exploration of the common bile duct (LCBDE) followed by laparoscopic cholecystectomy has gained popularity in children. The aim of this study was to investigate the outcomes of LCBDE in children and compare them with the treatment outcomes of previously used endoscopic retrograde cholangiopancreatography (ERCP). Methods: From January 2000 to January 2022, a total of 84 children (78.5% female) underwent laparoscopic cholecystectomy with a median follow-up of 11.4 (IQR 8, 14) years. Of these, 6 children underwent laparoscopic cholecystectomy (LC) + ERCP and 14 children underwent LCBDE for choledochiothiasis. The primary end point of the study was the success of treatment in terms of the incidence of complications, recurrence rate, and rate of reoperation. Secondary endpoints were stone characteristics, presenting symptoms, duration of surgery, and length of hospital stay. Results: The majority of patients were female in both groups (83.5% vs. 85.7%), mostly overweight with a median BMI of 27.9 kg/m2 and 27.4 kg/m2, respectively. Obstructive jaundice, colicky pain, acute pancreatitis, and obstruction of the papilla were the most common symptoms in both groups. The majority of patients (68%) had one stone, whereas two or more stones were found in 32% of patients. The median diameter of the common bile duct was 9 mm in both groups. The procedure was successfully completed in all patients in the ERCP group. In the group of patients treated with LCBDE, endoscopic extraction of the stone with a Dormia basket was successfully performed in ten patients (71.4%), while in the remaining four patients (28.6%) the stones were fragmented with a laser because extraction with the Dormia basket was not possible. The median operative time was 79 min in the LCBDE group (IQR 68, 98), while it was slightly longer in the ERCP group, 85 min (IQR 74, 105) (p = 0.125). The length of hospital stay was significantly shorter in the LCBDE group (2 vs. 4 days, p = 0.011). No complications occurred in the LCBDE group, while two (40%) complications occurred in the ERCP group: pancreatitis and cholangitis (p = 0.078). During the follow-up period, no conversions, papillotomies, or recurrences were recorded in either group. Conclusions: Exploration of the common bile duct and removal of stones by LCBDE is safe and feasible in pediatric patients for the treatment of choledocholithiasis. Through this procedure, choledocholithiasis and cholelithiasis can be treated in a single procedure without papillotomy or fluoroscopy. Compared with LC + ERCP, LCBDE is associated with a shorter hospital stay. The incidence of complications was rather low but not statistically significant.

Background: Laparoscopic common bile duct exploration (LCBDE) is the first choice of treatment for large common bile duct (CBD) stones. Recently, single-operator cholangioscopy (SpyGlass system) has been introduced widely in referral and large medical centers. Several studies have reported favorable results for treatment of large CBD stones guided by SpyGlass. We evaluated the clinical efficacy and safety of SpyGlass-guided laser lithotripsy LCBDE for treatment of large CBD stones.Methods: From August 2015 to August 2018, 157 patients with large bile duct stones who met the inclusion criteria were randomly divided into two groups: SpyGlass-guided laser lithotripsy (Group A) and LCBDE (Group B). The efficacy and complications were compared between the groups.Results: Although the first-session stone removal rate in Group A was significantly lower than that in Group B, Group A was not inferior to Group B in terms of total stone removal rate. Compared with Group B, Group A had shorter hospital stay and enhanced recovery. The short-term complication rates were also similar between the two groups.Conclusions: The clinical efficacy of SpyGlass-guided laser lithotripsy for the treatment of large CBD stones is not inferior to that of LCBDE, and it is less invasive. SpyGlass-guided laser lithotripsy is an important option for treatment of large CBD stones. [ABSTRACT FROM AUTHOR]

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) and less in laparoscopic than OCBDE. The mean intraoperative blood loss, bile leak, and postoperative wound infection were less in laparoscopic than OCBDE, and the mean operative time was less in open than LCBDE (P>0.05) but with no statistically significant difference. Conclusion LCBDE considered as a safe, efficient and preferred procedure for CBDE whenever possible. [ABSTRACT FROM AUTHOR]

While endoscopic retrograde cholangiopancreatography (ERCP) remains the primary treatment modality for common bile duct stones (CBDS) or choledocholithiasis due to advancements in instruments, surgical intervention, known as common bile duct exploration (CBDE), is still necessary in cases of difficult CBDS, failed endoscopic treatment, or altered anatomy. Recent evidence also supports CBDE in patients requesting single-step cholecystectomy and bile duct stone removal with comparable outcomes. This review elucidates relevant clinical anatomy, selection indications, and outcomes to enhance surgical understanding. The selection between trans-cystic (TC) vs trans-choledochal (TD) approaches is described, along with stone removal techniques and ductal closure. Detailed surgical techniques and strategies for both the TC and TD approaches, including instrument selection, is also provided. Additionally, this review comprehensively addresses operation-specific complications such as bile leakage, stricture, and entrapment, and focuses on preventive measures and treatment strategies. This review aims to optimize the management of CBDS through laparoscopic CBDE, with the goal of improving patient outcomes and minimizing risks., Competing Interests: Conflict-of-interest statement: Authors declare no conflict of interests for this article., (©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.)

Purpose: Gallstones are common in bariatric patients due to obesity and rapid weight loss. Bile duct stones after Roux-en-Y gastric bypass (RYGB) pose a technical challenge. We present our experience in management of bile duct stones following RYGB using laparoscopic-assisted endoscopic retrograde cholangiopancreatography (LA-ERCP). Materials and Methods: Retrospective review of RYGB patients who had endoscopic intervention for bile duct stones between 2010 and 2019. We assessed demographic and clinical outcomes. Results: There were 12 patients: 9 females, median age 64 years (range 34–73), median ASA score 3 (range 2–3), and median body mass index (BMI) 30 kg/m2 (range 24.4–46). Median time of presentation since RYGB was 5 years (range 6–96 months). Clinical presentations were biliary pain with deranged liver function tests (n = 8, 67%) and cholangitis (n = 4, 33%). Ten patients (83%) had cholecystectomy prior to presentation. LA-ERCP was performed in all 12 patients. It was successful in 10 patients (83%) of which 7 were performed as a primary intervention for bile duct stones and 3 were for residual stones following previous bile duct exploration. Two out of 12 LA-ERCPs (17%) were converted to open duct clearance. Median overall hospital stay was 2.5 days (range 1–10). One patient developed post-ERCP pancreatitis; one had chronic pain. There was no major complication or mortality. Conclusion: LA-ERCP is feasible for bile duct stones after RYGB and can clear the duct primarily or following previous surgical exploration. It also provides an opportunity to perform cholecystectomy and diagnostic laparoscopy. [ABSTRACT FROM AUTHOR]

Choledocholithiasis is a common presentation of symptomatic cholelithiasis that can result in biliary obstruction, cholangitis, and pancreatitis. A systematic English literature search was conducted in PubMed to determine the appropriate management strategies for choledocholithiasis. The following clinical spotlight review is meant to critically review the available evidence and provide recommendations for the work-up, investigations as well as the endoscopic, surgical and percutaneous techniques in the management of choledocholithiasis. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]