Search

Introduction: Although laparoscopic cholecystectomy has replaced the open surgery for management of gall bladder stones, however, bile duct stones or choledocholithiasis remains to be a challenging task. Bile duct stones are seen in almost every 7th to 10th patient having gall bladder stonesi. There is controversy regarding the ideal approach for management of common bile duct (CBD) gallstones, more so, in view of availability of multiple options. Until the laparoscopic and endoscopic modalities came into picture, open cholecyststectomy was the only procedure for CBD exploration. Materials and methods: Prospective Study was done in all patients with a diagnosis of choledocholithiasis in OPD in surgery department at Era's Lucknow Medical College and hospital posted for elective surgery. All the patients above 18 years of age presenting with uncomplicated choledocholithiasis undergoing elective CBD exploration were included. Patients with cholangitis, gall stone pancreatitis, abnormal liver enzymes (greater than thrice the upper limit of normal), immunocompromised patient were excluded. All patients with a diagnosis of choledocholithiasis in surgery OPD at ELMCH were chosen by SNOSE technique for open and laparoscopic CBD exploration. Demographic information was obtained. Blood specimen were obtained for hematological and biochemical assessment. Pre-operative sonographic assessment was also done and stone size was assessed. All patients received preoperative parental broad spectrum antibiotics. All procedures were operated by the same experienced surgical team, under general anesthesia. Results: Out of a total of 88 patients enrolled in the study, a total of 44 (50%) underwent CBD exploration using laparoscopic procedure and comprised the Group 1 of study whereas remaining 44 (50%) patients underwent CBD exploration using open procedure and comprised the Group 2 of study. Majority of patients in both the groups were female. Proportion of males was 36.4% and 34.1% respectively in Groups 1 and 2. Overall, there were 31 (35.2%) males and 57 (64.8%) females. On comparing the data statistically, no significant difference was observed between the two groups with respect to sex of the patients (p=0.823). Mean neutrophil, lymphocyte eosinophil and monocyte count was 68.45±7.19, 26.45±7.51, 4.23±1.79 and 0.82±1.02% respectively in Group 1 as compared to 68.30±7.61, 27.32±7.69, 3.95±1.82 and 0.61±1.10% respectively in Group 2. For none of these variables, the difference between two groups was significant (p>0.05). Mean prothrombin time and INR were 12.12±1.62 seconds and 0.70±0.14 respectively in Group 1 as compared to 12.20±1.47 seconds and 0.68±0.11 respectively in Group 2. Statistically, there was no significant difference between two groups for both these parameters (p>0.05). Conclusion: The findings of the study show that except for a slightly longer duration of procedure, laparoscopic procedure was associated with fewer complications (intraoperative blood loss, post-operative infection, wound dehiscence, residual stones and Incisional hernia), shorter duration of post-operative hospital stay and cheaper overall cost. Thus laparoscopic exploration of CBD offered a better clinical outcome with fewer outcomes and could be recommended as the preferred modality for exploration of CBD. [ABSTRACT FROM AUTHOR]

This article provides an overview of laparoscopic cholecystectomy (LC), a minimally invasive procedure for gallbladder removal. LC has become a widely accepted and safe alternative to open cholecystectomy (OC), although complications such as bile duct injury can still occur. The article also explores the use of LC for acute cholecystitis and laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis, as well as alternative procedures for challenging cases. The need for further research on preoperative assessment methods and the use of new technologies in LC is highlighted. Additionally, the article discusses studies comparing different surgical techniques for common bile duct stone removal, finding no significant difference in success rates but variations in adverse events and hospital stay duration. The authors recommend laparoscopic surgery for pediatric patients but note insufficient evidence to support its use in adults. The text concludes by emphasizing the importance of training in laparoscopic common bile duct exploration and its potential benefits. [Extracted from the article]

Background: Advancements in laparoscopic techniques led to the adoption of laparoscopic common bile duct exploration (LCBDE) as an alternative to endoscopic retrograde cholangiopancreatography (ERCP) for management of choledocholithiasis (CD). The goal of this study was to describe the initial experience at a safety net hospital with acute care surgeons performing LCBDE for suspected CD. We hypothesized LCBDE would reduce length of stay and hospital costs compared to laparoscopic cholecystectomy (LC) and ERCP performed in the same hospital admission. Methods: This was a retrospective case–control study from 2019 to 2023 comparing LCBDE to LC/ERCP among patients diagnosed with CD. Statistical analyses were performed using Mann–Whitney U tests for continuous variables and Chi-square tests for categorical variables. Data reported as median [interquartile range] or research subjects with condition (percentage). Results: A total of 110 LCBDE were performed, while 121 subjects underwent LC and ERCP. Patients in the LCBDE group were more likely to be female with a total of 87 female subjects (77.6%) compared to 76 male subjects (62.8%) (95% CI 1.14–3.74). Initial WBC was lower in the LCBDE group at 8.4 [6.9–11.8] compared to the LC/ERCP group at 10.9 [7.9–13.5] (p = 0.0013). Remaining demographics and lab values were similar between the two groups. Patients who underwent LCBDE had a significantly shorter length of stay at 2 days [1–3] compared to those in the LC/ERCP group at 4 days [3–6] (p < 0.001). Hospital charges for the LCBDE group were $46,685 [$38,687–$56,703] compared to $60,537 [$47,527–$71,739] for the LC/ERCP group (p < 0.001). Conclusion: LCBDE is associated with significantly lower hospital costs and shorter length of stay with similar post-operative complication and 30-day readmission rates. Our results show that LCBDE is safe and should be considered as a first-line approach in the management of CD. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Cholecystolithiasis combined with choledocholithiasis represents a prevalent disease. At present, regarding the management of the common bile duct (CBD), T‐tube drainage (TTD) and primary duct closure (PDC) emerge as two prominent approaches for biliary tract repair after laparoscopic CBD exploration (LCBDE). Here, retrospective analysis was conducted on the clinical records of 157 patients who underwent LCBDE at our hospital between January 2019 and January 2022. All patients were categorized into the PDC group or the TTD group based on the chosen CBD treatment approach. A comparative assessment was made across demographic factors, preoperative conditions, surgical particulars, and postoperative complications. The results showed that PDC is recommended for patients with a limited number of small stones, particularly when the CBD is in the 10–15 mm diameter range. [ABSTRACT FROM AUTHOR]

Background: Choledocholithiasis in children is commonly managed with an "endoscopy first" (EF) strategy (endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) under a separate anesthetic). Endoscopic Retrograde Cholangiopancreatography is limited at the end of the week (EoW). We hypothesize that a "surgery first" (SF) approach with LC, intraoperative cholangiogram (IOC), and possible laparoscopic common bile duct exploration (LCBDE) can decrease length of stay (LOS) and time to definitive intervention (TTDI). Methods: This is a retrospective single-center cohort study conducted between 2018 and 2023 in pediatric patients with suspected choledocholithiasis. Work week (WW) presentation included admission between Monday and Thursday. Time to definitive intervention was defined as time to LC. Results: 88 pediatric patients were identified, 61 managed with SF (33 WW and 28 EoW) and 27 managed with EF (18 WW and 9 EoW). Both SF groups had shorter mean LOS for WW and EoW presentation (64.5 h, 92.4 h, 112.9 h, and 113.0 h; P <.05). There was a downtreading TTDI in the SF groups (SF: WW 24.7 h and EoW 21.7 h; EF: WW 31.7 h and EoW 35.9 h; P =.11). 44 patients underwent LCBDE with similar success rates (91.6% WW and 85% EoW; P = 1.0). All EF patients received 2 procedures; 69% of SF patients were definitively managed with one. Conclusion: Children with choledocholithiasis at the EoW have a longer LOS and TTDI. These findings are amplified when children enter an EF treatment pathway. An SF approach results in shorter LOS with fewer procedures, regardless of the time of presentation. [ABSTRACT FROM AUTHOR]

This study aims to provide valuable references for clinicians in selecting appropriate surgical methods for biliary tract stones based on patient conditions. In this paper, the advantages and disadvantages of various minimally invasive cholelithiasis surgical techniques are systematically summarized and innovative surgical approaches and intelligent stone removal technologies are introduced. The goal is to evaluate and predict future research priorities and development trends in the field of gallstone surgery. In recent years, the incidence of gallstone-related diseases, including cholecystolithiasis and choledocholithiasis, has significantly increased. This surge in cases has prompted the development of several innovative methods for gallstone extraction, with minimally invasive procedures gaining the most popularity. Among these techniques, PTCS, ERCP, and LCBDE have garnered considerable attention, leading to new surgical techniques; however, it must be acknowledged that each surgical method has its unique indications and potential complications. The primary challenge for clinicians is selecting a surgical approach that minimizes patient trauma while reducing the incidence of complications such as pancreatitis and gallbladder cancer and preventing the recurrence of gallstones. The integration of artificial intelligence with stone extraction surgeries offers new opportunities to address this issue. Regarding the need for preoperative preparation for PTCS surgery, we recommend a combined approach of PTBD and PTOBF. For ERCP-based stone extraction, we recommend a small incision of the Oddi sphincter followed by 30 s of balloon dilation as the optimal procedure. If conditions permit, a biliary stent can be placed post-extraction. For the surgical approach of LCBDE, we recommend the transduodenal (TD) approach. Artificial intelligence is involved throughout the entire process of gallstone detection, treatment, and prognosis, and more AI-integrated medical technologies are expected to be applied in the future. [ABSTRACT FROM AUTHOR]

Introduction: This study aimed to study on clinical outcomes of single-stage (laparoscopic cholecystectomy [LC] and laparoscopic common bile duct [CBD] exploration using flexible videobronchoscope) versus dual-stage (endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy) for cholelithiasis with choledocholithiasis-prospective study in a tertiary care centre (BRACE STUDY-Bronchoscope-Assisted CBD Exploration [CBDE] Study). Patients and Methods: Between April 2022 and April 2023, patients who underwent LC with laparoscopic CBDE and endoscopic retrograde cholangiopancreatography (ERCP) followed by LC participated in this single-centre prospective research. The Institute Ethics Committee granted its approval after receiving an ethical review. The primary endpoint of the proposed research was the removal of the gall bladder and CBD stones. The secondary outcomes studied were complications using the Clavien-Dindo score, cost-effectiveness, patient satisfaction score and post-procedure duration of hospital stay. Results: A total of 168 patients were included in the study. The success rate of LC with laparoscopic CBD exploration using a flexible videobronchoscope (Group 1) was significantly higher as compared to ERCP f/b LC (Group 2) (96.4% vs. 84.5%, P value = 0.02). Out of the 84 patients in Group 1, direct choledochotomies were performed on 83 of them. Group 1 had a considerably shorter hospital stay (4.6 ± 2.4 vs. 5.3 ± 6.2 days; P = 0.03). Both the cost (P = 0.002) and the number of procedures per patient (P < 0.001) were considerably higher in Group 2. Major complications (Clavien-Dindo grade 3 and above) were significantly higher in Group 2 (P = 0.04). Patient satisfaction in Group 1 scored more favourably than those in Group 2 (2.26 ± 0.3 vs. 1.92 ± 0.7; P = 0.006). Conclusion: For concurrent gall bladder and CBD stones, single-stage management by LCBDE using a flexible videobronchoscope has a significantly better primary outcome and lower major complications than dual-stage management. The single-stage strategy also has advantages in terms of a shorter hospital stay, the need for fewer procedures, cost efficiency and patient satisfaction.

Abstract Background Endoscopic nasobiliary drainage (ENBD) is used as a drainage technique in patients with choledocholithiasis after stone removal. However, ENBD can cause discomfort, displacement, and other complications. This study aims to evaluate the safety of not using ENBD following elective clearance of choledocholithiasis. Methods Relevant studies were identified by searching PubMed, Web of Science, EMBASE, EBSCO, and Cochrane Library from their inception until August 2023. The main outcomes assessed were postoperative complications and postoperative outcomes. Subgroup analyses were conducted based on study design types and treatment procedures. Results Six studies, including three randomized controlled trials (RCTs) and three cohort studies, were analyzed. Among these, four studies utilized endoscopic techniques, and two employed surgical methods for choledocholithiasis clearance. The statistical analysis showed no significant difference in postoperative complications between the no-ENBD and ENBD groups, including pancreatitis (RR: 1.55, p = 0.36), cholangitis (RR: 1.81, p = 0.09), and overall complications (RR: 1.25, p = 0.38). Regarding postoperative outcomes, the subgroup analysis indicated that the bilirubin normalization time was longer in the no-ENBD group compared to the ENBD group in RCTs (WMD: 0.24, p = 0.07) and endoscopy studies (WMD: 0.23, p = 0.005), although the former did not reach statistical difference. There was also no significant difference in the length of postoperative hospital stay between the groups (WMD: -0.30, p = 0.60). Conclusion It appears safe to no- ENBD after elective clearance of choledocholithiasis.

The review provides an analysis of clinical studies and current clinical guidelines from the MEDLINE database on the PubMed platform regarding the treatment of choledocholithiasis. Choledocholithiasis occurs in almost 20 % of patients with gallstone disease and is characterized by frequent dangerous complications, in particular, bile duct obstruction, cholangitis, and biliary pancreatitis. Therefore, common bile duct exploration is an important component of surgical treatment for gallstone disease, but discussions about the optimal treatment for choledocholithiasis have been ongoing for many years. Currently, there is no generally accepted standard of treatment, and various methods and approaches to the staging and sequence of surgical interventions on the gallbladder and common bile duct are used. In recent years, the leading methods of choledocholithiasis treatment are minimally invasive endoscopic and/or laparoscopic interventions, which have almost completely replaced open surgeries. For common bile duct exploration and normalization of biliary excretion, endoscopic transpapillary (retrograde) access is used mostly, which is characterized by a high risk of post-procedural immediate and long-term complications. Endoscopic management of common bile duct stones requires an additional intervention — laparoscopic cholecystectomy, which is most often performed at the second stage or simultaneously with endoscopic intervention. The optimal staging and sequencing of interventions requires further research. A good alternative to endoscopic interventions on common bile duct is its laparoscopic exploration through the cystic duct or by choledochotomy (antegrade), which can be performed simultaneously with cholecystectomy. However, this technique has not yet been widely adopted, and immediate and long-term results are conflicting that require further research into the effectiveness and safety of the method. The effectiveness of surgical treatment for choledocholithiasis depends not only on the individual characteristics of a patient, including biliary anatomy, the form and severity of the disease, but also on the local experience and availability of appropriate equipment, which must be taken into account when planning treatment.

Background: Early reports suggested that previous abdominal surgery was a relative contraindication to laparoscopic cholecystectomy (LC) on account of difficulty and potential access complications. This study analyses different types/systems of previous surgery and locations of scars and how they affect access difficulties. As modified access techniques to minimise risk of complications are under-reported the study details and evaluates them. Method: Prospectively collected data from consecutive LC and common bile duct explorations (LCBDE) performed by a single surgeon over 30 years was analysed. Previous abdominal surgery was documented and peri-operative outcomes were compared with patients who had no previous surgery using Chi-squared analysis. Results: Of 5916 LC and LCBDE, 1846 patients (31.2%) had previous abdominal surgery. The median age was 60 years. Those with previous surgery required more frequent duodenal (RR 1.07; p = 0.023), hepatic flexure (RR 1.11; p = 0.043) and distal adhesiolysis (RR 3.57; p < 0.001) and had more access related bowel injuries (0.4% vs. 0.0%; p < 0.001). Previous upper gastrointestinal and biliary surgery had the highest rates of adhesiolysis (76.3%), difficult cystic pedicles (58.8%), fundus-first approach (7.2%), difficulty grades (64.9% Grades 3–5) and utilisation of abdominal drains (71.1%). Previous open surgery resulted in longer operative time compared to previous laparoscopic procedures (65vs.55 min; p < 0.001), increased difficulty of pedicle dissection (42.4% vs. 36.0%; p < 0.05) and required more duodenal, hepatic flexure and distant adhesiolysis (p < 0.05) and fundus-first dissection (4% vs 2%; p < 0.05). Epigastric and supraumbilical access and access through umbilical and other hernias were used in 163 patients (8.8%) with no bowel complications. Conclusion: The risks of access and adhesiolysis in patients with previous abdominal scars undergoing biliary surgery are dependent on the nature of previous surgery. Previous open, upper gastrointestinal and biliary surgery carried the most significant risks. Modified access techniques can be adopted to safely mitigate these risks. [ABSTRACT FROM AUTHOR]

This document is a collection of abstracts summarizing various research studies in the field of surgery. The abstracts cover a wide range of topics, including surgical techniques, complications, patient outcomes, ethical issues, and advancements in surgical practices. [Extracted from the article]

Situs inversus complicates diagnosis and treatment due to the mirrored organ placement in relation to normal anatomy. This report describes a 78‐year‐old female patient with situs inversus totalis who underwent laparoscopic cholecystectomy and laparoscopic common bile duct exploration for cholecystolithiasis and choledocholithiasis. Utilizing the "French mirror technique" for port placement, the surgeon adeptly mirrored standard maneuvers with a 2‐mm needle forceps in the left hand and a 5‐mm forceps in the right in a reversed anatomical setting. This technique maintained familiar hand movements, despite the patient's unique anatomy. The surgeon applied transcystic ductal bile duct exploration, using choledochoscopy for duct exploration and a basket catheter for stone removal. Laparoscopic cholecystectomy and common bile duct exploration through the transcystic ductal route are viable and effective for patients with situs inversus. [ABSTRACT FROM AUTHOR]

Introduction: This study aimed to study on clinical outcomes of single-stage (laparoscopic cholecystectomy [LC] and laparoscopic common bile duct [CBD] exploration using flexible videobronchoscope) versus dual-stage (endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy) for cholelithiasis with choledocholithiasis-prospective study in a tertiary care centre (BRACE STUDY-Bronchoscope-Assisted CBD Exploration [CBDE] Study). Patients and Methods: Between April 2022 and April 2023, patients who underwent LC with laparoscopic CBDE and endoscopic retrograde cholangiopancreatography (ERCP) followed by LC participated in this single-centre prospective research. The Institute Ethics Committee granted its approval after receiving an ethical review. The primary endpoint of the proposed research was the removal of the gall bladder and CBD stones. The secondary outcomes studied were complications using the Clavien-Dindo score, cost-effectiveness, patient satisfaction score and post-procedure duration of hospital stay. Results: A total of 168 patients were included in the study. The success rate of LC with laparoscopic CBD exploration using a flexible videobronchoscope (Group 1) was significantly higher as compared to ERCP f/b LC (Group 2) (96.4% vs. 84.5%, P value = 0.02). Out of the 84 patients in Group 1, direct choledochotomies were performed on 83 of them. Group 1 had a considerably shorter hospital stay (4.6 ± 2.4 vs. 5.3 ± 6.2 days; P = 0.03). Both the cost (P = 0.002) and the number of procedures per patient (P < 0.001) were considerably higher in Group 2. Major complications (Clavien-Dindo grade 3 and above) were significantly higher in Group 2 (P = 0.04). Patient satisfaction in Group 1 scored more favourably than those in Group 2 (2.26 ± 0.3 vs. 1.92 ± 0.7; P = 0.006). Conclusion: For concurrent gall bladder and CBD stones, single-stage management by LCBDE using a flexible videobronchoscope has a significantly better primary outcome and lower major complications than dual-stage management. The single-stage strategy also has advantages in terms of a shorter hospital stay, the need for fewer procedures, cost efficiency and patient satisfaction. [ABSTRACT FROM AUTHOR]

Background: The treatment of choledocholithiasis with nondilated common bile duct (CBD) is a challenge for surgeons who often choose endoscopic retrograde cholangiopancreatography with laparoscopic cholecystectomy (LC) staging surgery instead of simultaneous laparoscopic CBD exploration with LC because of the small CBD diameter. This study aims to introduce and assess the clinical applicability of a technique we developed to identify and extract CBD stones using laparoscopic ultrasound (LUS). Methods: We retrospectively reviewed surgical procedures and clinical data of 13 patients who underwent LC and CBD exploration using LUS between May 2022 and August 2023. The cystic duct was used for CBD stone removal. Results: Ten patients were successfully treated; 2 patients with residual stones were treated with ursodeoxycholic acid, whereas 1 patient required a microincision near the CBD and choledochoscopy because of stone incarceration in the duodenal papilla. The CBD diameter was 6 mm (5–9 mm). There were less than three CBD stones, with diameters of 2–6 mm; the median operative time was 105 minutes (range, 52–155 minutes). One patient developed postoperative cholangitis. The median postoperative hospital stay was 6 days (3–8 days). The stone clearance rate was 76.9%, and the CBD stone detection rate was 100%. No intraoperative complications, postoperative bile leakage, and mortality occurred. Conclusions: CBD exploration and transcystic stone extraction under LUS guidance are safe and effective approaches for patients with choledocholithiasis; strict control over surgical indications is necessary. This study could provide new strategies for effectively treating choledocholithiasis. [ABSTRACT FROM AUTHOR]

Background: Bariatric surgery patients may develop common bile duct stones, and the alterations in their anatomy present challenges in treating this condition. Methods such as laparoscopic bile duct exploration is impractical in many healthcare facilities, due to the absence of a choledochoscope. This study assesses the feasibility of laparoscopic exploration of the common bile duct using a disposable bronchoscope in these individuals. Method: The study involved 32 participants who had undergone gastric bypass surgery. These participants presented with both bile duct stones and bile ducts exceeding 8 mm in diameter, diagnosed through either MRCP or cholangiography conducted during the surgery. Stone extraction was carried out through either choledotomy or transcystic routes using a disposable bronchoscope and endoscopic baskets. Results: The patients' ages ranged from 27 to 66 years, with a mean bile duct diameter of 11.6 mm (SD 3.1 mm). A 100% stone clearance rate was achieved for all patients. None of the patients required conversion to open surgery. No T-tubes were placed. One patient developed biloma and intra-abdominal abscesses, which were successfully treated with a percutaneous drain over the course of a week. No mortalities were recorded during the course of this study. Conclusion: Our study results demonstrate that laparoscopic bile duct exploration is both feasible and safe in patients who have undergone gastric bypass surgery. The utilization of a disposable bronchoscope emerges as a practical and cost-effective alternative to a choledochoscope in this procedure. [ABSTRACT FROM AUTHOR]

Key Clinical Message Cholecystolithiasis combined with choledocholithiasis represents a prevalent disease. At present, regarding the management of the common bile duct (CBD), T‐tube drainage (TTD) and primary duct closure (PDC) emerge as two prominent approaches for biliary tract repair after laparoscopic CBD exploration (LCBDE). Here, retrospective analysis was conducted on the clinical records of 157 patients who underwent LCBDE at our hospital between January 2019 and January 2022. All patients were categorized into the PDC group or the TTD group based on the chosen CBD treatment approach. A comparative assessment was made across demographic factors, preoperative conditions, surgical particulars, and postoperative complications. The results showed that PDC is recommended for patients with a limited number of small stones, particularly when the CBD is in the 10–15 mm diameter range.

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 and study aim: The development of a new cholangioscope, the SpyGlass™ Discover (Boston Scientific), has allowed the laparoscopic transcystic common bile duct exploration and stone clearance. The possibility of simultaneous treatment of choledocholithiasis during early laparoscopic cholecystectomy offers the opportunity to enormously reduce the time between acute cholecystitis diagnosis and the execution of cholecystectomy with better outcomes for patients. Furthermore, an altered anatomy of the gastrointestinal tract is not an obstacle to this technique. The aim of the study was to determine whether this new procedure is feasible, safe, and effective. Patients and methods: The investigation employs a retrospective case series study including all consecutive patients with a diagnosis of common bile duct stones undergoing cholecystectomy and intraoperative laparoscopic common bile duct clearance using SpyGlass™ Discover at IRCCS Policlinico San Matteo in Pavia (Italy). Eighteen patients were included from May 2022 to May 2023. Results: A complete clearance of the common bile duct was obtained in 88.9% of patients. The mean postoperative length of stay was 3 days. No major complications occurred. After a median follow-up of 8 months, no recurrence of biliary events or readmissions occurred. Conclusion: This procedure has proven to be feasible, safe, and effective. [ABSTRACT FROM AUTHOR]

Backgrounds: Laparoscopic common bile duct exploration (LCBDE) has been shown to be effective in managing choledocholithiasis whilst avoiding ERCP‐related complications. However, patient and technical factors effects outcome. This study aimed to explore the matters effecting the failure of LCBDE. Methods: All patients who underwent a laparoscopic cholecystectomy (LC) between 2007 and 2021 were identified using a prospective database. Data were collected for patients who underwent LCBDE including demographics, pre‐operative investigations, intra‐operative findings, technique of bile duct clearance and clearance rates, and post‐operative outcomes. Predictors of failed LCBDE were identified. Results: Laparoscopic cholecystectomy was performed in 3648 patients. Of these, 374 underwent LCBDE for suspected choledocholithiasis. Choledochoscopy was most frequently used (58.8%) with a success rate of 84.1%. Small cystic duct diameter (4.7 vs. 3.4 mm, P = 0.002), stone size >6 mm (P = 0.02), stone: cystic duct ratio >1 (P = 0.04), and >3 stones was associated with failed LCBDE by univariate analysis. Small cystic duct diameter (OR: 0.45, 95% CI: 0.26–0.77, P = 0.004) and stone size >6 mm (OR: 0.23, 95% CI: 0.06–0.92), P = 0.04) correlated with failure by multivariate analysis. Failed LCBDE was associated with increased length of stay (6.6 days vs. 3.1 days, P = 0.001), however the rate of serious complications or mortality was unaffected. Conclusion: LCBDE is safe and effective in managing choledocholithiasis. Factors such as cystic duct diameter, size and number of CBD stones, and stone: cystic duct ratio are associated with increased likelihood of inadequate clearance. The presence of these factors can help clinicians in decision making during LCBDE to improve chance of success. [ABSTRACT FROM AUTHOR]

IntroductionCholedocholithiasis, a common complication of gallstone disease, poses significant risks including cholangitis and pancreatitis. Various treatment approaches exist, including single-stage and two-stage techniques, with recent literature suggesting advantages of the single-stage approach in terms of outcomes and cost-effectiveness. This study evaluates the feasibility, efficacy, and safety of single-stage laparoscopic cholecystectomy combined with intraoperative endoscopic retrograde cholangiopancreatography (LC + iERCP) compared to the previously adopted two-stage approach.MethodsA retrospective analysis was conducted on patients undergoing single-stage LC + iERCP for cholecysto-choledocholithiasis during the COVID-19 pandemic (2020–2022). Data on demographics, preoperative assessments, intraoperative parameters, and postoperative outcomes were collected and compared with an historical control group undergoing the two-stage approach (LC + preopERCP). Hospitalization costs were also compared between the two groups.ResultsA total of 190 patients were included, with 105 undergoing single-stage LC + iERCP. The single-stage approach demonstrated successful completion without cystic duct cannulation, with no conversions to open surgery. Operative time was comparable to the two-stage approach, while hospital stay, and costs were significantly lower in the single-stage group. Complication rates were similar between the groups.ConclusionsSingle-stage LC + iERCP appears to be a feasible, effective, and safe approach for treating cholecysto-choledocholithiasis, offering potential benefits in terms of reduced hospital stay, OR occupation time, and costs compared to the two-stage approach. Integration of this approach into clinical practice warrants consideration, unless there are logistical challenges that cannot be overcome or lack of endoscopic expertise also for treating challenging urgent cases.

Background: Approximately 10% of intraoperative cholangiograms identify choledocholithiasis (CDL), stones in the common bile duct. Choledocholithiasis management options include endoscopic retrograde cholangiopancreatography (ERCP) followed by cholecystectomy, laparoscopic cholecystectomy (LC) followed by ERCP (LC + ERCP), cholecystectomy with open common bile duct exploration, or laparoscopic cholecystectomy with laparoscopic common bile duct exploration (LC + LCBDE). The goal of these interventions is to clear the obstruction from CDL. Methods: Patients from a single-center community hospital undergoing LC with intraoperative cholangiogram (LC + IOC) progressing to LC + LCBDE from July 2020 to August 2022 were evaluated for hospital length of stay (LOS), operative times, and complications. These were compared to the prior standard practice of pre/post-operative ERCP. Results: The results were evaluated using ANOVA, Student-Newman-Keuls, and chi square analysis. In comparison of LC + CBDE to ERCP + cholecystectomy, LOS was reduced (1.8 vs 4.6 days P <.0001). No difference in LOS between LC + IOC and LC + CBDE (1.4 vs 1.8 days, P >.05) was found. No difference in complication rates was found. Mean operative time differed between LC + IOC and LC + CBDE (63 vs 113 minutes, P <.0001). Fifty-five attempts of LC + CBDE were performed with only 10 requiring post-operative ERCP. Discussion: Since implementation of LC + CBDE, there has been reduced LOS without increasing complication rates. Operative times are increased with LC + CBDE but offset by reduced LOS, additional anesthesia events, and procedures. Our institution will continue to pursue LC + CBDE when indicated with efforts to improve resource allocation. [ABSTRACT FROM AUTHOR]

The article discusses the management of choledocholithiasis (gallstones in the bile duct) in pediatric patients. The lack of consensus on the optimal treatment approach, limited resources for pediatric patients, and reliance on adult gastroenterologists for therapeutic procedures can make management challenging. Currently, the standard treatment involves two stages: endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). However, a single-stage approach involving laparoscopic common bile duct exploration (LCBDE) has been proposed as an alternative. The study aimed to identify missed opportunities for single-stage intervention by examining the endoscopic findings of patients who underwent an ERCP-first approach. The majority of patients had findings that could be treated with LCBDE, suggesting that a surgery-first approach could be an efficient alternative. [Extracted from the article]

Laparoscopic common bile duct exploration (LCBDE) utility in management of choledocholithiasis may decrease length of stay and patient cost, but postoperative management remains widely debated. We examined periprocedural LFTs for patients undergoing LCBDE and endoscopic retrograde cholangiopancreatography (ERCP) speculating for trend existence after successful LCBDE. We hypothesized that postoperative LCBDE LFTs would not downtrend even after successful ductal clearance. We identified 99 patients under 18 who underwent ERCP or LCBDE with at least one pre- and post-procedural LFT. Periprocedural LFTs between groups were compared using Wilcoxon signed-rank tests. The 22 ERCP patients demonstrated a significant downtrend across Tbili (P <.001), AST (P =.001), ALT (P =.002), and ALP (P <.001). The 27 LCBDE patients demonstrated a significant downtrend in Tbili (P =.002) only, while AST (P >.05), ALT (P >.05), and ALP (P >.05) were nonsignificant. Lack of consistent downtrend in the LCBDE group raises doubt regarding the utility of postoperative LFTs for post-procedural management. [ABSTRACT FROM AUTHOR]

Endoscopic retrograde cholangiopancreatography (ERCP) is invasive for pancreaticobiliary diseases. Perforation is a rare but severe complication among its associated risks. A 45-year-old female with biliary colic and multiple gallbladder calculi was diagnosed with choledocholithiasis based on imaging showing CBD dilation and gallstones. ERCP was planned for stone removal. Sphincterotomy was performed, but stone retrieval attempts failed, leading to severe pneumo-peritoneum and respiratory compromise. Immediate CBD stenting was done, avoiding surgical intervention. The patient recovered uneventfully, later undergoing laparoscopic cholecystectomy with CBD exploration and stone removal. ERCP-related perforations, rare but severe, involve retroperitoneal air collection. Clinical signs include abdominal discomfort, and imaging confirms diagnosis. Management varies by type, with some requiring surgical repair. Conservative management sufficed in this case, with successful patient recovery. ERCP-related complications like pneumo-peritoneum require prompt diagnosis and conservative management if no perforation is evident. [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: As a minimally invasive treatment for common bile duct (CBD) stones, ultrasound-guided percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) is gaining attention and recognition from the medical community. Methods: A retrospective analysis was conducted on patients with CBD stones treated in our hospital from January 2016 to April 2022. Patients were divided into three groups: 77 treated with PTCSL, 93 with endoscopic retrograde cholangiopancreatography (ERCP), and 103 with laparoscopic common bile duct exploration (LCBDE). Their clinical data, perioperative indicators, and complications were analyzed comparatively. Then, risk factors for the post-PTCSL recurrence of CBD stones were analyzed by logistic regressions. Finally, the receiver operating characteristic curve was drawn. Results: All perioperative indicators of the PTCSL group were better than the LCBDE group (P < 0.001). The incidences of cholangitis, hemobilia, and incisional infection after surgery were lower in the PTCSL group than in the LCBDE group (P < 0.05). Pancreatitis, reflux esophagitis, and papillary stenosis occurred less frequently in the PTCSL group than in the ERCP group (P < 0.05). Logistic regression analysis indicated that gallstones and family history were independent risk factors. The AUC for recurrent CBD stones predicted by multi-indicators was 0.895 (95% CI 0.792–0.999, P < 0.001) with a sensitivity of 96.7% and specificity of 68.8%. Conclusions: Ultrasound-guided PTCSL is a safe and effective treatment for CBD stones. Patients recovered quickly with fewer postoperative complications. It can be a first-line treatment for CBD stones. Gallstones and family history are independent risk factors for recurrent CBD stones, which provide a reference for clinicians in identifying the high-risk population needing close follow-up. [ABSTRACT FROM AUTHOR]

Introduction: Inspissated bile syndrome and choledocholithiasis are rare causes of obstructive jaundice in neonates. Laparoscopic common bile duct exploration (LCBDE) is a method for clearing the common bile duct employed in adults and older children but is rarely reported in neonates. Case presentation: We present a case series of 3 infants who underwent LCBDE in the setting of inspissated bile syndrome and/or choledocholithiasis. LCBDE was utilized to power flush the inspissated bile/choledocholithiasis and was successful. Patient 1 was noted to have a dilated common bile duct (CBD) in the setting of inspissated bile. A glidewire was utilized to gain access to the common bile duct via micropuncture needle through the abdominal wall directly into the gallbladder to allow for distal power flushing resulting in successful clearance of the duct noted by repeat cholangiogram. Patient 2 presented with elevated LFTs and dilated CBD with unclear etiology. In a similar fashion to patient 1, access was gained via wire to allow for power flushing resulting in duct clearance. Patient 3, presented with choledocholithiasis and wire access was obtained, however this time via a transcystic ductotomy with a catheter able to be directed to the common bile duct for distal power flushing resulting in duct clearance. Conclusion: These cases highlight the convergence of techniques and equipment gleaned from other types of procedures and indications that allowed us to tailor the surgical approach for definitive clearance of the biliary system. Level of evidence: IV.

Abstract Background For patients with choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) is preferred over open surgery. Whether primary closure of the common bile duct (CBD) should be performed upon completion of choledochotomy remains unclear, and the corresponding indications for primary closure of the common bile duct have yet to be fully identified. This study was performed to evaluate the safety and feasibility of primary closure of CBD among elderly patients (≥ 70 years) after LCBDE. Methods Patients with choledocholithiasis who had undergone LCBDE with primary closure of the CBD between July 2014 and December 2020 were retrospectively reviewed. Included patients were assigned into two groups (Group A: ≥70 years and Group B:

Chunlong Zhao,1,2,&ast; Zipeng Xu,1,&ast; Weidong Hu,1,&ast; Chen Ge,1 Zhengwei Zhang,1 Zhengxing Dai,3 Shuo Zhang,4 Neng Tang,4 Weiguo Wang,3 Jiayu Gu,3 Chaobo Chen,1,4,5 Songbing He2 1Department of General Surgery, Xishan People’s Hospital of Wuxi City, Wuxi, People’s Republic of China; 2Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, People’s Republic of China; 3Department of Interventional and Vascular Surgery, Xishan People’s Hospital of Wuxi City, Wuxi, People’s Republic of China; 4Department of Hepatic-Biliary-Pancreatic Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, People’s Republic of China; 5Department of Immunology, Ophthalmology & ORL, Complutense University School of Medicine, Madrid, Spain&ast;These authors contributed equally to this workCorrespondence: Chaobo Chen; Songbing He, Email bobo19820106@gmail.com; hesongbing1979@suda.edu.cnBackground: Laparoscopic cholecystectomy (LC) with laparoscopic common bile duct exploration (LCBDE) is convenient in treating cholelithiasis and choledocholithiasis due to its advantage of accelerated recovery. This retrospective study aimed to summarize the experience of cholelithiasis and choledocholithiasis treatment via three-port approach of LCBDE in Eastern China.Methods: Patients diagnosed with cholelithiasis and choledocholithiasis between July 2019 and October 2021 were included. Patients who received LC+LCBDE+primary suturing of the common bile duct (CBD) via a three-port approach were assigned to the LCBDE-P group, and those who received LC+LCBDE+T-tube drainage of CBD comprised the LCBDE-T group. The measurement data were compared between the two groups. P-values < 0.05 indicated statistical significance.Results: A total of 88 patients were divided into two groups: LCBDE-P (n=50) and LCBDE-T (n=38). Multiple logistic regression analysis showed that LCBDE-P is associated with a shorter length of stay (OR=0.115, 95% CI: 0.040– 0.329, P< 0.001) and lower hospitalization costs (OR=0.120, 95% CI: 0.041– 0.357, P< 0.001). No significant differences between the two groups were detected in the operation time, intraoperative hemorrhage, clearance rate of CBD stones, postoperative liver function, and postoperative complications (P> 0.05).Conclusion: The three-port approach of LCBDE is a safe and feasible strategy for managing cholelithiasis and choledocholithiasis. Compared to LCBDE-T, LCBDE-P reduces the length of hospital stay and medical costs during hospitalization.Keywords: cholelithiasis, choledocholithiasis, laparoscopic cholecystectomy, laparoscopic common bile duct exploration, primary suture, T-tube drainage

Background: Although laparoscopic common bile duct exploration (LCBDE) is considered a safe and effective method for the removal of bile duct stones, selecting primary duct closure (PDC) or T-tube drainage (TTD) following choledochotomy remains controversial. This study aims to explore the clinical effects of PDC and TTD after LCBDE. Methods: We retrospectively analyzed clinical data of 348 patients with choledocholithiasis treated with LCBDE from January 2016 to October 2020. All patients were divided into PDC (225 cases) and TTD (123 cases) groups. Propensity score matching (PSM) was performed. We compared operative parameters and outcomes. Results: After matching (n = 116/group), no significant difference was observed between the two groups (P > 0.05) regarding intra-abdominal infection, incision infection, bile leakage, and retained stones. In terms of operation time, intraoperative blood loss, postoperative hospital stay, postoperative exhaust time, postoperative antibiotic use time, and postoperative abdominal drainage time, PDC group was obviously superior to TTD group (P

This article provides information on the management of common bile duct stones in a tertiary care hospital in India. The study found that common bile duct stones were more common in females between the ages of 55 and 64. The study compared the success rates of open surgery and endoscopic procedures, with open surgery being slightly more successful. Complications such as pancreatitis and hemorrhage were observed in some cases. The authors emphasize the importance of individualized treatment and the availability of experienced doctors. The study also provides data on the age distribution and symptoms of patients with common bile duct stones, with pain being the most common symptom. The success rate of endoscopic procedures was 85.3%, while open CBD exploration had a success rate of 85.7%. Complications occurred in a small percentage of cases, with a mortality rate of 1.5% for endoscopic procedures. The study concludes that open surgery is more successful, but further research is needed for validation. [Extracted from the article]

Objective: To compare the overall efficacy of laparoscopic common bile duct exploration(LCBDE) with endoscopic retrograde cholangiopancreatography (ERCP) after cholecystectomy. Methods: From January 2017 to July 2021, Seventy patients with Choledocholithiasis after cholecystectomy who were admitted to our hospital were selected and divided into ERCP and LCBDE groups. comparison of baseline characteristics, clinical efficacy and postoperative complications between the ERCP and LCBDE. Results: ①The overall efficacy rate of LCBDE was 97.1%, while the overall efficacy rate in the ERCP group was 76.6%. The LCBDE group demonstrated a significantly higher overall effective rate compared to the ERCP group, with a statistically significant difference (p < 0.05). ②The preoperative and postoperative complications of the LCBDE group were visibly lower than the other group (P < 0.05). The postoperative time to oral intake, postoperative ventilation time, length of hospital stay, and hospital costs were higher in the ERCP group compared to the LCBDE group, with a statistically significant difference (P < 0.05). Conclusion: In the treatment of common bile duct stones after cholecystectomy, LCBDE is a superior choice compared to ERCP in terms of stone diameter, quantity, clearance rate, and hospital costs. [ABSTRACT FROM AUTHOR]

Laparoscopic transcystic common bile duct exploration during laparoscopic cholecystectomy is the treatment of choice for patients with coexisting gallbladder and bile duct stones. Failure of this usually indicates laparoscopic choledocotomy, after which most patients are managed with primary duct closure and less frequently with T-tube placement or bilioenteric anastomosis. The objective of this paper is to describe the indications and complications of T-tube placement after laparoscopic choledocotomy in a consecutive series of single-stage management of 554 patients. Case series analysis of a prospectively collected historical database of all patients treated with T-tube drainage at Cosme Argerich Hospital from July 2008 and December 2020. Surgical indications and postoperative management will be discussed. Five hundred fifty-four patients underwent simultaneous scheduled laparoscopic cholecystectomy and common bile duct exploration during the analyzed period. One hundred thirteen (20.39%) required laparoscopic choledochotomy, after which 54 (48%) were treated with T-tube drainage, 23 for suspicion of incomplete bile duct clearance, 16 for impaired papillary drainage, 13 for inappropriate bile duct wall conditions, and 2 for lateral bile duct injuries. No significant morbidity was related to T-tube drainage. In our setting, and following a strict protocol, T-tube drainage after laparoscopic choledochotomy is a valid alternative to primary duct closure in selected patients. [ABSTRACT FROM AUTHOR]

Laparoscopic common bile duct exploration (LCBDE) remains underutilized in the management of common bile duct (CBD) stones. The exact cause of this under-utilization remains unclear; however, identified barriers to LCBDE implementation include lack of training and unavailability of dedicated instruments. LCBDE is an attractive alternative for stone retrieval in patients with Roux-en-Y gastric bypass given the anatomical difficulty in endoscopic retrograde cholangiopaneatography (ERCP). Direct visualization through choledochoscopy is the method of choice for LCBDE. However, dedicated choledoscopes are expensive and not widely available, which may lead surgeons to seek for alternatives at their particular environment. With the COVID-19 pandemic, disposable bronchoscopes have become widely accessible at our institution, raising the possibility of using one for direct vision of the biliary tract. We present the case of a 61-year-old male with past medical history of Roux-en-Y gastric bypass, who presented to the emergency department with a CBD stone. Successful LCBDE was achieved with the aid of a disposable bronchoscope for direct visualization of the biliary tract. [ABSTRACT FROM AUTHOR]

Background Laparoscopic cholecystectomy (LC) plus either intraoperative endoscopic retrograde cholangiopancreatography (intraERCP) or laparoscopic common bile duct exploration (LCBDE) are one-stage, minimally invasive procedures to treat cholecysto-choledocholithiasis. This study aimed to compare the safety, efficacy, and surgical outcomes of the LC-intraERCP and LC-LCBDE for patients with cholecysto-choledocholithiasis. Both authors completely performed both procedures. Patients and methods This multicenter randomized controlled trial included 218 patients with cholecystocholedocholithiasis randomized to LC-intraERCP (n=109) and LC-LCBDE (n=109) treatment groups between February 2019 and October 2022. The primary outcome was a technical success, while conversion to open surgery, operative time, morbidity, mortality, length of hospital stay, and cost were considered secondary outcomes. Results Both groups had no significant differences in success (94.5% for LC-intraERCP and 87.2% for LC-LCBDE) and morbidity rate. The conversion to open surgery, the mean operative time, the length of hospital stay, and the cost were significantly lower in the LC-intraERCP. There was no mortality in either group. Conclusion LC-intraERCP is safer and more effective than LC-LCBDE for treating cholecystocholedocholithiasis. Moreover, it is associated with reduced hospital stay and cost. [ABSTRACT FROM AUTHOR]

B Results: b Ten patients(10%) had TT. 29 patients(30%) had torsion appendix testis; and 31 patients(32%) had epididymitis/orchitis; no pathologies were identified in the remaining patients. B Results: b A total of 64 patients were included, at least one parathyroid gland was identified in all patients with naked eyes, 55 (85.9%) patients with AF, and 58 (90.6%) patients with ICG. Post-operatively, 66.7% of patient achieved continence at 1 month post-operative; 94.7% of patients achieved continence at 3 months post-operatively; 100% of patient achieved continence at 6 months and 12 months post-operatively. Out of 22 patients, 20 patients (90.9%) had pathological T2 staging while two patients (9.1%) had pathological T3a staging. Among the 91 patients analysed, 24 patients (26.4%) were "long survivors" and 67 patients (73.6%) were "normal survivors". [Extracted from the article]

There is little research to evaluate laparoscopic transcystic common bile duct (CBD) exploration (LTCBDE) as a diagnostic test to identify choledocholithiasis undergoing laparoscopic cholecystectomy (LC). This study aimed to assess the technical success and safety of LTCBDE in patients with suspected choledocholithiasis but negative magnetic resonance cholangiopancreatography (MRCP) undergoing LC. We did an ambispective cohort study in patients with gallstones and suspected CBD stones but negative MRCP undergoing LC. The primary outcomes were the rate of complications in the hospital. Between January 2010 and December 2018, 620 patients (median age, 58 years; 58.4% female) were eligible for the study. The success rate of LTCBDE was 91.8% and CBD stones were observed in 53.3% with a stone clearance rate of 99.3%. The overall postoperative complication rate was 0.65% and no death was recorded in the total cohort. Notably, the morbidity in LTCBDE is 0.53%. Retained CBD stones were diagnosed in 2 patients and managed by ERCP successfully. In the LTCBDE cohort, the median duration of operation was 78 (60–100) min and the median postoperative hospital stay was 1 (1–2) days. Overall, at a mean follow-up of 4.1 (2.3–6.1) years, recurrent CBD stones occurred in 1.1% and all-cause mortality in 0.6%. LTCBDE should be considered the favored choice in the diagnostic algorithm for patients with suspected choledocholithiasis but negative MRCP undergoing LC. [ABSTRACT FROM AUTHOR]

The article explores the effectiveness of long-term expectant management for patients with asymptomatic common bile duct (CBD) stones and a non-dilated CBD. The study found that 70.8% of patients were able to clear their CBD stones without additional procedures, while 29.2% required endoscopic sphincterotomy (ES) to achieve clearance. However, ES resulted in complications in 15.8% of cases. The study suggests that long-term expectant management can be an option for patients with non-dilated CBD stones, but ES may be necessary in some cases. [Extracted from the article]

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

Background: There are risks of choledocholithiasis in symptomatic gallstones, and some surgeons have proposed the identification of choledocholithiasis before cholecystectomy. Our goal was to evaluate the diagnostic accuracy of the latest guidelines and create computational prediction models for the accurate prediction of choledocholithiasis. Methods: We retrospectively reviewed symptomatic gallstone patients hospitalized with suspected choledocholithiasis. The diagnostic performance of 2019 and 2010 guidelines of the American Society for Gastrointestinal Endoscopy (ASGE) and 2019 guideline of the European Society of Gastrointestinal Endoscopy (ESGE) in different risks. Lastly, we developed novel prediction models based on the preoperative predictors. Results: A total of 1199 patients were identified and 681 (56.8%) had concurrent choledocholithiasis and were included in the analysis. The specificity of the 2019 ASGE, 2010 ASGE, and 2019 ESGE high-risk criteria was 85.91%, 72.2%, and 88.42%, respectively, and their positive predictive values were 85.5%, 77.4%, and 87.3%, respectively. For Mid-risk patients who followed 2019 ASGE about 61.8% of them did not have CBD stones in our study. On the choice of surgical procedure, laparoscopic cholecystectomy + laparoscopic transcystic common bile duct exploration can be considered the optimal treatment choice for cholecysto-choledocholithiasis instead of Endoscopic Retrograde Cholangio-Pancreatography (ERCP). We build seven machine learning models and an AI diagnosis prediction model (ModelArts). The area under the receiver operating curve of the machine learning models was from 0.77 to 0.81. ModelArts AI model showed predictive accuracy of 0.97, recall of 0.97, precision of 0.971, and F1 score of 0.97, surpassing any other available methods. Conclusion: The 2019 ASGE guideline and 2019 ESGE guideline have demonstrated higher specificity and positive predictive value for high-risk criteria compared to the 2010 ASGE guideline. The excellent diagnostic performance of the new artificial intelligence prediction model may make it a better choice than traditional guidelines for managing patients with suspected choledocholithiasis in future. [ABSTRACT FROM AUTHOR]

Background: For patients with choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) is preferred over open surgery. Whether primary closure of the common bile duct (CBD) should be performed upon completion of choledochotomy remains unclear, and the corresponding indications for primary closure of the common bile duct have yet to be fully identified. This study was performed to evaluate the safety and feasibility of primary closure of CBD among elderly patients (≥ 70 years) after LCBDE. Methods: Patients with choledocholithiasis who had undergone LCBDE with primary closure of the CBD between July 2014 and December 2020 were retrospectively reviewed. Included patients were assigned into two groups (Group A: ≥70 years and Group B: <70 years) according to age. Group A was compared with Group B in terms of preoperative characteristics, intraoperative results and postoperative outcomes. Results: The mean operative time for Group A was 176.59 min (± 68.950), while the mean operative time for Group B was 167.64 min (± 69.635) (P = 0.324). The mean hospital stay after surgery for Group A was 8.43 days (± 4.440), while that for Group B was 8.30 days (± 5.203) (P = 0.849). Three patients in Group A experienced bile leakage, while bile leakage occurred in 10 patients in Group B (3.8% vs. 4.5%, P = 0.781). Group A was not significantly different from Group B in terms of postoperative complications and 30-day mortality except pneumonia (P = 0.016), acute cardiovascular event (P = 0.005) and ICU observation (P = 0.037). After a median follow-up time of 60 months, 2 patients in Group A and 2 patients in Group B experienced stone recurrence (2.5% vs. 0.9%, P = 0.612). One patient in Group A experienced stenosis of the CBD, while stenosis of the CBD occurred in 5 patients in Group B (1.3% vs. 2.2%, P = 0.937). Conclusions: Primary closure of CBD upon completion of LCBDE could be safely performed among patients ≥ 70 years. [ABSTRACT FROM AUTHOR]

Although laparoscopic common bile duct exploration (LCBDE) is considered a safe and effective method for the removal of bile duct stones, selecting primary duct closure (PDC) or T-tube drainage (TTD) following choledochotomy remains controversial. This study aims to explore the clinical effects of PDC and TTD after LCBDE. We retrospectively analyzed clinical data of 348 patients with choledocholithiasis treated with LCBDE from January 2016 to October 2020. All patients were divided into PDC (225 cases) and TTD (123 cases) groups. Propensity score matching (PSM) was performed. We compared operative parameters and outcomes. After matching (n = 116/group), no significant difference was observed between the two groups (P > 0.05) regarding intra-abdominal infection, incision infection, bile leakage, and retained stones. In terms of operation time, intraoperative blood loss, postoperative hospital stay, postoperative exhaust time, postoperative antibiotic use time, and postoperative abdominal drainage time, PDC group was obviously superior to TTD group (P < 0.05). Primary closure following LCBDE is considered a safe and effective alternative to T-tube drainage. • The data of 348 patients were collected retrospectively in our department. • Propensity score matching was performed to reduce the deviation. • The combination of hand–drawn diagrams and intraoperative photos was adopted. • Primary closure is considered a safe and effective alternative to T-tube drainage. [ABSTRACT FROM AUTHOR]

Purpose: Previous gastrectomy (PG) can lead to an increased incidence of biliary stones. However, the success rate of endoscopic retrograde cholangiopancreatography after gastrectomy remains low. In such cases, laparoscopic common bile duct exploration (LCBDE) may be an alternative. The aim of this study was to evaluate the safety and feasibility of LCBDE for patients who underwent PG. Methods: A retrospective analysis of patients with a history of LCBDE was conducted. Patients were divided into two groups according to their PG status, and their perioperative data were compared. Results: The outcomes of 27 patients with a history of gastrectomy were compared with those of 155 without a history of gastrectomy who underwent LCBDE. PG patients experienced longer hospitalization times (P = 0.006), more postoperative bleeding (p = 0.021), a lower incidence of preoperative endoscopic retrograde cholangiopancreatography (P < 0.001), and a higher incidence of T-tube application (p = 0.002) than those without gastrectomy. However, there were no significant differences in estimated blood loss volume, operation time, bile leakage status, pancreatitis status, stone clearance rate, readmission rate, or recurrence rate. Conclusions: Although LCBDE following gastrectomy may require laborious perioperative management, a history of gastrectomy might not influence the feasibility or safety of LCBDE, as its perioperative outcomes are comparable to those in patients without a history of gastrectomy. [ABSTRACT FROM AUTHOR]