Laparoscopic common bile duct exploration with T-tube choledochotomy for the management of choledocholithiasis

Although laparoscopic cholecystectomy (LC) has become the gold standard for the management of gallstone disease, the application of laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis has been slower. The aim of this study is to determine the feasibility and effectiveness of LCBDE. A retrospective cohort study was conducted to compare LCBDE (n = 82) with conventional common bile duct exploration (CCBDE) (n = 75) and endoscopic sphincterotomy (EST) (n = 80) in the management of choledocholithiasis. All our LCBDEs were performed through choledochotomy with T-tube placement. The mean operative time of the LCBDE group (124 +/- 48 minutes) was not significantly longer then the CCBDE group (118 +/- 35 minutes), while the postoperative hospitalization was shorter in both the LCBDE (8 +/- 5 days) and EST (9 +/- 4 days) groups than in the CCBDE (13 +/- 6 days) group. In the LCBDE group, 14 patients (17.1%) required postoperative choledochoscopy to clear residual stones through the T-tube tract. The only mortality occurred in the CCBDE group. The morbidity rate was 3.7% (3/82) in the LCBDE group, including bile leakage in 1 case and bile peritonitis in 2 cases; 6.7% (5/75) in the CCBDE group, including atlectasis in 2 cases, sepsis in 1, and wound infection in 2. There were 2 cases of postoperative pancreatitis (2.5%; 2/80) in the EST group. The difference in the average number of sessions needed for complete clearance of choledocholithiasis in each group was statistically significant (EST, 1.46 +/- 0.67; LCBDE, 1.23 +/- 0.42; and CCBDE, 1.09 +/- 0.28; P < 0.0001). Our results suggested that EST and LCBDE tended to require more therapeutic sessions then CCBDE, although these sessions were less invasive. The benefits of LCBDE include minimal invasiveness, concurrent treatment of gallbladder stone and CBD stones in a single session, and a shorter postoperative hospital stay. However a longer learning curve is needed. Selection of the most suitable therapeutic option for individual patients by an experienced surgeon gives the most benefits to patients.     

Laparoscopic common bile duct exploration by choledochotomy

Background: Management of cholelithiasis and choledocholithiasis usually requires two separate teams—the gastroenterologist/surgical endoscopist and the laparoscopic surgical team. This requires two separate procedures that potentially increase the overall morbidity and cost. Laparoscopic common bile duct exploration by choledochotomy (LCBDE-C) averts this problem with a single approach. Methods: In 1990–1991, unsuspected stones found at laparoscopy with intraoperative cholangiogram done routinely underwent postoperative ERCP. Residual stones had been found after ERCP in 16 of 22 preoperative ERCP patients and we began to seek an alternative technique. Laparoscopic common bile duct exploration by choledochotomy has achieved a high rate of success. Results: Technically successful LCBDE-C has been accomplished in 143 of 148 patients (96.6%). Retained bile duct stones have been found on postoperative cholangiogram in three patients (2.0%), all of which have been successfully removed by postoperative ERCP. Thus 140 or 148 patients had their bile duct successfully cleaned by the one-step technique alone (94.6%). Conclusions: We believe that most laparoscopic surgeons who have acquired the skills of intracorporeal suturing can be successful at laparoscopic common bile duct exploration by choledochotomy. The disadvantage of T-tube presence will likely be eliminated by future developments with intraoperative antegrade sphincterotomy-like procedures, but the ability to see both proximal and distal biliary tree with the choledochotomy in all cases seems to offer more than adequate results at this point in the evolution of the laparoscopic approach to calculus biliary tract disease. Received: 3 April 1997/Accepted: 18 September 1997     

腹腔镜胆总管探查胆总管一期缝合54例体会

目的探讨胆道探查术后一期缝合胆总管的可行性及手术指征和手术方法。方法 2010年12月~2015年6月,采用联合腹腔镜及胆道镜实施胆总管切开取石、胆总管一期缝合术54例。结果根据术前病历选择标准实施的54例手术均获得成功,手术时间68~137 min,平均92 min。术中出血20~150 m L,平均82 m L;术后住院5~14天,平均6.8天。3例术后胆漏,经腹腔引流1周至12天后痊愈,其余51例术后48~72 h拔出腹腔引流管。术后随访1个月至3年,复查彩超均未发现结石残留及胆道狭窄。结论腹腔镜胆总管探查胆总管一期缝合术治疗胆总管结石具有创伤小、住院时间短及并发症少的优势,但应严格把握适应证及掌握操作技巧。     

Results of laparoscopic bile duct exploration via choledochotomy

Background: Laparoscopic bile duct exploration (LBDE) is well established although the results via choledochotomy are relatively poorly documented. This report evaluates the results achieved by a single surgeon operating in one institution on an unselected group of patients using modern instrumentation. Methods: Over a 3‐year period, 56 consecutive patients underwent LBDE via choledochotomy utilizing flexible choledochoscopy. Results: The median age was 61 years (range 20–90) and the mean body mass index was 29 (21–47). There were 15 patients (27%) who had emergency operations for jaundice with a mean preoperative bilirubin level of 108 umol/L (41–248). Fourteen patients (25%) had undergone failed preoperative endoscopic retrograde cholangiopancreatography. Contact electrohydraulic lithotripsy was used in 8 patients (14%) and t‐tubes were inserted in 6 patients (11%) with the remainder having primary closure. There was major morbidity in 6 patients (11%) including conversion to open surgery in 1 and relaparoscopy in 3. Three patients had positive t‐tube cholangiograms giving a laparoscopic clearance rate of 93% (52 patients). The median postoperative length of stay was 2.5 days (1–15). The median follow‐up was 56.1 weeks (interquartile range 23.4–110.7) with no recurrent stones, strictures or late gallstone abscess. Conclusions: LBDE via choledochotomy is safe and effective but there is a definite morbidity rate. It requires significant investment in equipment, and skill with flexible endoscopy and laparoscopic suturing.     

Laparoscopic choledochotomy for bile duct stones

In the era of laparoscopic surgery, treatment strategies for common bile duct stones remain controversial. Laparoscopic choledochotomy is usually indicated only when transcystic duct exploration is not feasible. However, laparoscopic choledochotomy provides complete access to the ductal system and has a higher clearance rate than the transcystic approach. In addition, primary closure of the choledochotomy with a running suture and absorbable clips facilitates the procedure. Therefore, to avoid postoperative biliary stenosis, all patients with bile duct stones can be indicated for choledochotomy, except for those with nondilated common bile duct. Placement of a C-tube also provides access for the clearance of possible retained stones by endoscopic sphincterotomy as a backup procedure. C-tube placement, in contrast to T-tube insertion, is advantageous in terms of a relatively short hospital stay. In conclusion, laparoscopic choledochotomy with C-tube drainage is recommended as the treatment of choice for patients with common bile duct stones. Received: February 27, 2001 / Accepted: March 19, 2001     

56例腹腔镜胆总管切开取石术不放置T管引流的临床经验

[摘要] 目的 探讨腹腔镜、胆道镜微创手术治疗胆总管结石的疗效。方法 选取2011年5月份至2012年10月份56例施行微创手术治疗胆总管结石的病例。既往均无胆总管结石手术史,无胆道狭窄畸形,排除胆管及周围恶性肿瘤病变;无肝内胆管结石,肝外胆管无残留结石;胆总管壁增厚扩张范围在1 cm～2 cm,无明显急性炎性改变;术中胆总管十二指肠开口通畅。结果 56例患者均顺利完成手术,3例术后出现胆瘘,2例出现肺部感染,2例出现尿潴留。所有病例均顺利出院,无出现切口感染,无围手术期死亡。结论 腹腔镜联合胆道镜治疗胆总管结石,行胆总管一期缝合,取石疗效确切,创伤小,无需留置T管,患者术后恢复快,住院周期短。     

腹腔镜胆总管探查一期缝合术治疗复发性胆总管结石的临床分析

目的探讨腹腔镜胆总管探查(laparoscopic common bile duct exploration,LCBDE)一期缝合术治疗复发性胆总管结石的可行性和安全性。方法回顾性分析2010年1月至2014年6月间行LCBDE一期缝合术的45例复发性胆总管结石病人的临床资料。结果 45例病人无中转开腹及围手术期死亡病例。术中2例分别损伤横结肠、十二指肠球部浆膜。手术时间为76~155 min,平均(108.5±35.4)min;术中出血量为10~115 ml,平均(35.6±10.5)ml;术后肛门排气时间为1~4d,平均(1.2±0.5)d;术后住院时间为5~15 d,平均(7.2±3.2)d。术后并发症总发生率为6.25%(3/48),其中胆漏2例,高淀粉酶血症1例,均经保守治疗后治愈;无再手术病例。43例病人完成术后1年随访,随访率为93.75%,均经影像学检查证实无胆管狭窄、胆管残留结石或结石复发等并发症。结论选择性LCBDE一期缝合术治疗复发性胆总管结石是安全有效的,短期预后良好。但术者需具备丰富的腹腔镜操作经验,并灵活地把握手术适应证。     

胆总管探查后一期缝合的经验和认识

目的 探讨胆总管探查后一期缝合的经验和认识。方法对1990年1月至2004年6月因肝外胆管结石择期行胆总管探查后一期缝合的271例作一回顾性分析。所有病例不含肝内胆管结石，术中经胆道镜或胆道造影排除胆道残石并常规放置右肝下引流管。结果术后14例腹腔引流液含胆汁，均未特殊处理。术后平均住院8．73d。所有病例术后3个月内门诊B超复查，未发现胆道残石。216例（79．70%）获得远期随访，无一例发现肝外胆管狭窄。结论对经过严格选择的肝外胆管结石病例，胆总管探查后不应强调一律放置T管。术中精细操作和经术中胆道镜或胆道造影检查排除残石后，一期缝合可作为术式选择。     

Laparoscopic exploration of common bile duct in difficult choledocholithiasis

Background This review investigated the role played by laparoscopic exploration of the common bile duct (LECBD) in the management of difficult choledocholithiasis.Methods This retrospective study reviewed a prospective database of LECBD for difficult choledocholithiasis during the period 1995 to 2003.Results Of the 97 LECBDs performed in the authors center from 1995 to 2003, 25 were performed for difficult choledocholithiasis. Difficult choledocholithiasis was defined as failure of endoscopic stone retrieval for the following reasons: access and cannulation difficulty, the difficult nature of common bile duct (CBD) stones, and the presence of endoscopic retrograde cholangiopancreatography (ERCP)-related complications. There were seven unsuccessful cannulations because of previous gastrectomy (n = 5) and periampullary diverticulum (n = 2). Among the 18 patients with failed endoscopic extraction, there were 10 impacted stones, 2 incomplete stone clearances after multiple attempts, 2 type 2 Mirizzi syndromes, 1 proximal stent migration, 1 repeated post-ERCP pancreatitis, 1 situs inversus, and 1 stricture at the distal common bile duct. There were 14 male and 11 female patients with a mean age of 67.8 ± 15 years. Initial presentations included cholangitis (n = 14, 56%), biliary colic (n = 3, 12%), jaundice/deranged liver function (n = 5, 20%), cholecystitis (n = 2, 8%), and pancreatitis (n = 1, 4%). Regarding the approach for LECBD, there were 2 transcystic duct explorations and 23 choledochotomies. The mean operative time was 149.4 ± 49.3 min, and there were three conversions (12%). The stone clearance rate was 100%, and no recurrence was detected during a mean follow-up period of 16.8 months. Five complications were encountered, which included bile leak (3 patients) and wound infection (2 patients). When the results were compared with the remaining 72 LECBDs for nondifficult stones during the same period, the complication rate, conversion rate, and rate of residual stones were similar despite a longer operation time (149.4 ± 49.4 min vs 121.6 ± 50.5 min).Conclusion When ERCP is impossible or stone retrieval is incomplete, LECBD is the solution to difficult CBD stones.     

Primary closure of choledochotomy after emergency laparoscopic common bile duct exploration

Introduction  The debate into whether or not to drain the common bile duct after laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis continues. Reports are in favour of primary closure of choledochotomy in elective setting. The aim of this study is to evaluate our experience in the primary closure of choledochotomy in emergency setting by analysing indications, operative time, hospital stay, complications, and outcome. Methods  All patients undergoing LCBDE were prospectively entered into a database incorporating demographic and clinical data including mode of admission, indication for surgery, operation details and clinical outcome. All operations were performed by the same consultant (A. Baker). Results  All 81 patients had primary closure after LCBDE between October 2003 and April 2007. The male to female ratio was 1:3. Median age was 68 years (range 19–90 years). Nineteen (23%) patients had obstructive jaundice, 4 (5%) had cholangitis, 7 (8.6%) had acute pancreatitis, 9 (11.1%) had failed ERCP, and 42 (51.8%) had biliary colic or cholecystitis with positive intraoperative cholangiogram (IOC). Those patients were divided into two groups: elective LCBDE (ElLCBDE) (n = 33, 41%) and emergency LCBDE (EmLCBDE) (n = 48, 59%). There was no significant difference in the median operative time, median hospital stay and complication rate. Total laparoscopic clearance rate in this series was 95%. Conclusions  To our knowledge, this is the first publication in the literature in which primary closure after laparoscopic common bile duct exploration in emergency setting was used. With no significant difference in operative time, hospital stay and complications, in experienced hands primary closure of CBD in emergency settings is safe and feasible.     

胆总管内置“支撑内引流管”一期缝合微创治疗胆管结石

目的:探讨腹腔镜胆总管探查、胆总管置管内引流、一期缝合的可行性及效果。 方法:对61例行腹腔镜联合胆道镜胆总管探查，胆总管置入 “胆道支撑内引流管”，一期缝合胆总管患者的临床资料进行回顾性分析。 结果:61 例手术均获成功，手术时间 80～260 min，平均 125 min。术后发生胆漏 3 例，戳孔内遗留结石 1 例，戳孔疝 1 例。内引流管于术后 5～7 d 拔除。随访 3～24 个月，无残余结石及胆管狭窄等并发症。 结论:腹腔镜胆总管探查、胆总管置管内引流、一期缝合是安全可行的。     

Common bile duct exploration for choledocholithiasis

Laparoscopic common bile duct exploration has a high success rate, with rates reported from 83% to 96% in recent years. The morbidity rate has been reported to be approximately 10% Mortality rates are very low, at less than 1%.     

腹腔镜胆总管探查术治疗胆总管结石合并胆囊结石

目的 探讨腹腔镜胆总管探查术( LC BDE)治疗胆总管结石合并胆囊结石的临床疗效和价值.方法 2006年7月至2010年6月期间对127例胆总管结石合并胆囊结石患者进行微创治疗.其中78例采用LCBDE+腹腔镜胆囊切除术(LC)治疗,49例采用内镜十二指肠括约肌切开术(EST) +LC治疗.比较二组的手术治疗成功率、术后并发症发生率、残余结石率、胃肠功能恢复时间、住院时间和费用等指标,并随访二组远期并发症发生率.结果 LCBDE+ LC组:手术成功率94.87％,术后并发症发生率5.41％.EST+LC组:手术成功率95.92％,术后并发症发生率12.77％.两组手术成功率差异无统计学意义(P＞0.05),术后并发症发生率差异有统计学意义(P＜0.05).手术时间、住院费用的比较差异有统计学意义(P＜0.05).出院后随访1～5年,平均(3.2±0.8)年,LCBDE+LC组结石复发率、胆管积气发生率、反流性胆管炎发生率显著低于EST+LC组(P＜0.05).结论 LCBDE+LC是治疗胆囊结石合并胆总管结石的安全、有效、可行的微创术式,对于适宜的患者行胆总管一期缝合更能体现微创的优势.     

腹腔镜胆总管探查一期缝合治疗老年胆总管结石的临床疗效分析

目的:探讨老年胆总管结石患者行腹腔镜胆总管探查(LCBDE)一期缝合的安全性与有效性。方法:回顾性分析2012年12月—2016年12月期间收治的146例胆囊结石合并胆总管结石行LCBDE一期缝合患者的临床与随访资料,根据年龄分两组,61例≥65岁者为老年组,85例65岁为非老年组。比较两组患者的相关临床指标。结果:146例患者LCBDE一期缝合手术均顺利完成,无中转开腹。与非老年组比较,老年组手术时间(90.98 min vs.93.12 min)、术中出血量(25.08 mL vs.24.94 mL)、胆总管结石数(2.36个vs.1.98个)差异均无统计学意义(均P0.05),术后腹腔引流时间(4.74 d vs.4.13 d)、下床时间(1.87 d vs.1.61 d)、胃肠功能恢复时间(2.43 d vs.2.05 d)、住院时间(7.46 d vs.6.62 d)明显延长(均P0.05)。两组均无严重并发症发生,两组术后胆汁漏(9.8%vs.9.4%)、术后腹腔出血(1.6%vs.2.4%)、残余结石(1.6%vs.1.2%)、结石复发率(1.6%vs.0)差异均无统计学意义(均P0.05)。结论:LCBDE一期缝合处理老年胆总管结石安全、有效,在准确把握手术指证前提下,可作为老年胆总管结石患者优先选择的术式。     

Primary closure versus T-tube drainage after common bile duct exploration for choledocholithiasis

Purpose  

The aim of this study was to evaluate the benefits and harms of primary closure versus T-tube drainage after common bile duct (CBD) exploration for choledocholithiasis.     

腹腔镜下胆管切开取石一期胆管缝合应用于高龄患者的安全性探讨

目的：探讨腹腔镜下胆管切开取石后一期缝合胆管而不放置胆管引流在高龄患者中的安全性和可行性。方法回顾性分析2007年1月至2012年10月接受腹腔镜下胆管切开取石后不放置胆管引流的高龄病例临床资料,共16例作为研究组,收集同时期接受腹腔镜下胆管切开取石不放置胆管引流管的非高龄病例20例作为对照组。对比分析两组患者的平均手术时间、住院时间、术后并发症情况等。结果两组患者术后均康复出院。研究组平均手术时间为（116.31±11.31）min,平均住院时间（10.19±1.22）d;而对照组平均手术时间为（106.80±10.58）min,平均住院时间（7.65±0.88）d;两组比较差异无统计学意义。两组均无胆漏、腹腔出血、膈下感染及术后阻塞性黄疸等术后并发症。两组的切口感染、肺部感染率和结石复发率差异无统计学意义。结论腹腔镜下胆管切开取石后一期缝合胆管而不放置胆管引流用于高龄患者是安全、可行的。     

胆总管结石腹腔镜胆总管探查术后一期缝合与T管引流的临床比较

目的:比较胆总管结石腹腔镜胆总管探查术(LCBDE)后一期缝合与T管引流的临床疗效。方法:回顾分析2012年1月—2014年12月接受LCBDE的142例胆总管结石患者临床资料,其中一期缝合75例,放置T管引流67例,比较两种方式的相关临床指标并分析术后并发症的危险因素。结果:两种手术方式患者间,术前指标除性别有所差异外(P=0.028),其余均无统计学差异(均P0.05);手术时间、术后并发症发生率、手术死亡率、结石复发率均无统计学差异(均P0.05),一期缝合患者术后住院时间明显低于放置T管患者(P0.05)。两种手术方式的主要并发症均为胆瘘,其中一期缝合者发生7例(9.3%),T管引流者发生8例(11.9%);比较胆瘘患者与无胆瘘患者间相关因素,未发现术后胆瘘相关风险因素(均P0.05)。结论:LCBDE后一期缝合治疗胆总管结石安全有效,其效果与放置T管引流相似且术后住院时间明显缩短。胆瘘的相关风险因素还有赖于大样本的数据资料及前瞻性随机对照研究确定。     

腹腔镜胆总管探查取石一期缝合术的研究进展

胆总管结石是最常见的普外科疾病之一,其患病率约占我国胆石症患者的5％～29％[1].腹腔镜下胆总管探查取石术(laparoscopic common bile duct exploration,LCBDE)是治疗胆总管结石的重要手段,胆总管的闭合方式主要有T管引流和一期缝合(primary duct closure,P...