Laparoscopic endobiliary stenting: a simplified approach to the management of occult common bile duct stones

Three years ago we described laparoscopic placement of biliary stems as an adjunct to laparoscopic common bile duct exploration (LCBDE) in 16 patients. We now present a modification of our technique and experience with 48 additional patients. Laparoscopic cholecystectomy with intraoperative fluorocholangiography (LC/IOC) performed in 372 consecutive patients during a 36-month period revealed common bile duct stones (CBDS) in 48 patients (12.9%). In this series, LCBDE was not performed and no attempt was made to clear CBDS prior to transcystic stent placement. Stent placement added 9 to 26 minutes of operative time to LC/IOC alone. Forty-four patients (92%) were discharged after surgery and four (8%) were observed overnight. Outpatient endoscopic retrograde cholangiopancreatography 1 to 4 weeks later succeeded in clearing CBDS in all patients. All stents were retrieved without difficulty and 3- to 36-month follow-up demonstrates no surgical, endoscopic, or stent-related complications to date. Laparoscopic biliary stent placement for the treatment of CBDS is a safe, rapid, technically less challenging alternative to existing methods of LCBDE. It preserves the benefits of minimally invasive surgery for patients, and virtually assures success of postoperative endoscopic retrograde cholangiopancreatography with complete stone clearance. Presented at the Forty-First Annual Meeting of The Society for Surgery of the Alimentary Tract, San Diego, Calif., May 2l–24, 2000 (poster presentation).     

A stratified intraoperative surgical strategy is mandatory during laparoscopic common bile duct exploration for common bile duct stones

Background: Open exploration and endoscopic sphincterotomy (ES) remain the preferred treatment of common bile duct stones (CBDS). The recent spread of laparoscopy has worsened the dilemna of choosing between surgical and endoscopic treatment of CBDS. The aim of this study was to critically evaluate the results of our preliminary experience with laparoscopic common bile duct exploration (CBDE) for CBDS. Methods: Ninety-two consecutive patients were prospectively submitted to laparoscopic CBDE. Surgical strategy included an initial transcystic approach or laparoscopic choledochotomy. Failure of stone clearance was managed by conversion to open CBDE or by postoperative ES. Electrohydraulic lithotripsy and papillary balloon dilatation were selectively used. Stone clearance was assessed by choledochoscopy and control cholangiography. Results: The overall laparoscopic stone clearance in this series was 84% (transcystic route 63% and choledochotomy 93%). Conversion to laparotomy was mandatory in 12% of the patients because of incomplete stone clearance and in 5% because of intraoperative complications. Postoperative ES was required in 4% of the patients, giving an overall surgical success rate of 96%. When indicated (small and limited number of stones located below the cysticocholedochal junction, with a dilated and patent cystic duct) the transcystic route had the lower success rate, the higher complication rate, and the shorter operative time and postoperative hospital stay. When indicated (accessible and dilated common bile duct over 7 mm), laparoscopic choledochotomy had the higher success rate, the lower complication rate, the longer operative time, and the longer postoperative hospital stay, which is related to associated external biliary drainage. The hospital mortality included two high-risk patients (2%) and the complications rate was 15%. Conclusions: Laparoscopic CBDE is safe in selected patients. A stratified intraoperative surgical strategy is mandatory in deciding between a transcystic route and choledochotomy with specific indications for each approach. When feasible, laparoscopic choledochotomy is more efficient and safe than the transcystic route, but it is associated with a longer postoperative hospital stay, which is due to external biliary drainage. Received: 7 May 1996/Accepted: 19 November 1996     

Laparoscopic common bile duct exploration

Background: Herein I describe my >12-year experience with laparoscopic common bile duct exploration (LCBDE). Methods: From 21 September 1989 through 31 December 2001, 3,580 patients presented with symptomatic biliary tract disease. Laparoscopic cholecystecomy (LC) was attempted in 3,544 of them (99.1%) and completed in 3,527 (99.5%). Laparoscopic cholangiograms (IOC) were performed in 3,417 patients (96.4%); in 344 cases (9.7%), the IOC was abnormal. Forty-nine patients (1.4%) underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP), and 33 patients (0.9%) underwent postoperative ERCP. LCBDE was attempted in 326 cases and completed in 321 (98.5%). It was successful in clearing the duct in 317 of the 344 patients with abnormal cholangiograms (92.2%). Results: The mean operating time for all patients undergoing LC with or without cholangiograms or LCBDE or other additional surgery was 56.9 min. Mean length of stay was 22.1 h. The mean operating time for LC only patients (n = 2530)—that is, those not undergoing LCBDE or any other additional procedure—was 47.6 min; their mean postoperative length of stay was 17.2 h. Ductal exploration was performed via the cystic duct in 269 patients, (82.5%) and through a choledochotomy in 57 patients (17.5%). T-tubes were used in patients in whom there was concern for possible retained debris or stones, distal spasm, pancreatitis, or general poor tissue quality secondary to malnutrition or infection. In cases where choledochotomy was used, a T-tube was placed in 38 patients (67%), and primary closure without a T-tube was done in 19 (33%). There were no complications in the group of patients who underwent choledochotomy and primary ductal closure without T-tube placement or in the group in whom T-tubes were placed. Conclusions: Common bile duct (CBD) stones still occur in 10% of patients. These stones are identified by IOC. IOC can be performed in >96.4% of cases of LC. LCBDE was successful in clearing these stones in 97.2% of patients in whom it was attempted and in 92.2% of all patients with normal IOCs. Most LCBDEs in this series were performed via the cystic duct because of the stone characteristics and ductal anatomy. Selective laparoscopic placement of T-tubes in patients requiring choledochotomy (67%) appears to be a safe and effective alternative to routine T-tube drainage of the ductal system. ERCP, which was required for 5.8% of patients with abnormal cholangiograms, and open CBDE, which was used in 2.0%, still play an important role in the management of common bile duct pathology. The role of ERCP, with or without sphincterotomy, has returned to its status in the prelaparoscopic era. LCBDE may be employed successfully in the vast majority of patients harboring CBD stones.     

Laparoscopic CBD Exploration

Laparoscopic CBD exploration (LCBDE) is a cost effective, efficient and minimally invasive method of treating choledocholithiasis. Laparoscopic Surgery for common bile duct stones (CBDS) was first described in 1991, Petelin (Surg Endosc 17:1705–1715, 2003). The surgical technique has evolved since then and several studies have concluded that Laparoscopic common bile duct exploration(LCBDE) procedures are superior to sequential endolaparoscopic treatment in terms of both clinical and economical outcomes, Cuschieri et al. (Surg Endosc 13:952–957, 1999), Rhodes et al. (Lancet 351:159–161, 1998). We started doing LCBDE in 1998.Our experience with LCBDE from 1998 to 2004 has been published, Gupta and Bhartia (Indian J Surg 67:94–99, 2005). Here we present our series from January 2005 to March 2009. In a retrospective study from January 2005 to March 2009, we performed 3060 laparoscopic cholecystectomies, out of which 342 patients underwent intraoperative cholangiogram and 158 patients eventually had CBD exploration. 6 patients were converted to open due to presence of multiple stones and 2 patients were converted because of difficulty in defining Calots triangle; 42 patients underwent transcystic clearance, 106 patients had choledochotomy, 20 patients had primary closure of CBD whereas in 86 patients CBD was closed over T-tube; 2 patients had incomplete stone clearance and underwent postoperative ERCP. Choledochoduodenosotomy was done in 2 patients. Patients were followed regularly at six monthly intervals with a range of six months to three years of follow-up. There were no major complications like bile leak or pancreatitis. 8 patients had port—site minor infection which settled with conservative treatment. There were no cases of retained stones or intraabdominal infection. The mean length of hospital stay was 3 days (range 2–8 days). LCBDE remains an efficient, safe, cost-effective method of treating CBDS. Primary closure of choledochotomy in select patients is a viable & safe option with shorter operative time and length of stay. LCBDE can be performed successfully with minimal morbidity & mortality.     

Laparoscopic endobiliary stenting as an adjunct to common bile duct exploration

Background: The management of common bile duct stones (CBDS) in the era of operative laparoscopy is evolving. Several minimally invasive techniques to remove CBDS have been described, including preoperative endoscopic retrograde cholangiopancreatography (ERCP), postoperative ERCP, lithotripsy, laparoscopic transcystic common bile duct exploration, and laparoscopic choledochotomy with common bile duct exploration (CBDE). Because of the risks and limitations of these procedures, we utilize laparoscopically placed endobiliary stents as an adjunct to CBDE. Methods: Sixteen patients underwent laparoscopic common bile duct exploration (LCBDE) by either choledochotomy or the transcystic technique with placement of endobiliary stents. These patients were identified during laparoscopic cholecystectomy as having occult choledocholithiasis, using routine dynamic intraoperative cholangiography. Results: CBDS were successfully removed in all patients as demonstrated by completion cholangiography and intraoperative choledochoscopy. Eighty percent of patients were discharged the following day; the first three patients in this series were observed for 48 h prior to discharge. No patient required T-tube placement and closed suction drains were removed the morning after surgery. Stents were removed endoscopically at 1 month. Six- to 30-month follow-up demonstrates no complications to date. Conclusions: Laparoscopic endobiliary stenting reduces operative morbidity, eliminates the complications of T-tubes, and allows patients to return to unrestricted activity quickly. We recommend laparoscopically placed endobiliary stents in patients undergoing LCBDE.     

Postoperative ERCP versus laparoscopic choledochotomy for clearance of selected bile duct calculi: a randomized trial

OBJECTIVE: Prospectively evaluate whether for patients having laparoscopic cholecystectomy with failed trans-cystic duct clearance of bile duct (BD) stones they should have laparoscopic choledochotomy or postoperative endoscopic retrograde cholangiography (ERCP). SUMMARY BACKGROUND DATA: Clinical management of BD stones found at laparoscopic cholecystectomy in the last decade has focused on pre-cholecystectomy detection with ERCP clearance in those with suspected stones. This clinical algorithm successfully clears the stones in most patients, but no stones are found in 20% to 60% of patients and rare unpredictably severe ERCP morbidity can result in this group. Our initial experience of 300 consecutive patients with fluoroscopic cholangiography and intraoperative clearance demonstrated that, for the pattern of stone disease we see, 66% of patients' BD stones can be cleared via the cystic duct with dramatic reduction in morbidity compared to the 33% requiring choledochotomy or ERCP. Given the limitations of the preoperative approach to BD stone clearance, this trial was designed to explore the limitations, for patients failing laparoscopic trans-cystic clearance, of laparoscopic choledochotomy or postoperative ERCP. METHODS: Across 7 metropolitan hospitals after failed trans-cystic duct clearance, patients were intraoperatively randomized to have either laparoscopic choledochotomy or postoperative ERCP. Exclusion criteria were: ERCP prior to referral for cholecystectomy, severe cholangitis or pancreatitis requiring immediate ERCP drainage, common BD diameter of less than 7 mm diameter, or if bilio-enteric drainage was required in addition to stone clearance. Drain decompression of the cleared BD was used in the presence of cholangitis, an edematous ampulla due to instrumentation or stone impaction and technical difficulties from local inflammation and fibrosis. The ERCP occurred prior to discharge from hospital. Mechanical and extracorporeal shockwave lithotripsy was available. Sphincter balloon dilation as an alternative to sphincterotomy to allow stone extraction was not used. Major endpoints for the trial were operative time, morbidity, retained stone rate, reoperation rate, and hospital stay. RESULTS: From June 1998 to February 2003, 372 patients with BD stones had successful trans-cystic duct clearance of stones in 286, leaving 86 patients randomized into the trial. Total operative time was 10.9 minutes longer in the choledochotomy group (158.8 minutes), with slightly shorter hospital stay 6.4 days versus 7.7 days. Bile leak occurred in 14.6% of those having choledochotomy with similar rates of pancreatitis (7.3% versus 8.8%), retained stones (2.4% versus 4.4%), reoperation (7.3% versus 6.6%), and overall morbidity (17% versus 13%). CONCLUSIONS: These data suggest that the majority of secondary BD stones can be diagnosed at the time of cholecystectomy and cleared trans-cystically, with those failing having either choledochotomy or postoperative ERCP. However, because of the small trial size, a significant chance exists that small differences in outcome may exist. We would avoid choledochotomy in ducts less than 7 mm measured at the time of operative cholangiogram and severely inflamed friable tissues leading to a difficult dissection. We would advocate choledochotomy as a good choice for patients after Billroth 11 gastrectomy, failed ERCP access, or where long delays would occur for patient transfer to other locations for the ERCP.     

Role of laparoscopic common bile duct exploration in the management of choledocholithiasis

Surgical fraternity has not yet arrived at any consensus for adequate treatment of choledocholithiasis. Sequential treatment in the form of pre-operative endoscopic retrograde cholangio-pancreatography followed by laparoscopic cholecystectomy(LC) is considered as optimal treatment till date. With refinements in technique and expertise in field of minimal access surgery, many centres in the world have started offering one stage management of choledocholithiasis by LC with laparoscopic common bile duct exploration(LCBDE). Various modalities have been tried for entering into concurrent common bile duct(CBD) [transcystic(TC) vs transcholedochal(TD)], for confirming stone clearance(intraoperative cholangiogram vs choledochoscopy), and for closure of choledochotomy(T-tube vs biliary stent vs primary closure) during LCBDE. Both TC and TD approaches are safe and effective. TD stone extraction is involved with an increased risk of bile leaks and requires more expertise in intra-corporeal suturing and choledochoscopy. Choice depends on number of stones, size of stone, diameter of cystic duct and CBD. This review article was undertaken to evaluate the role of LCBDE for the management of choledocholithiasis.     

腹腔镜超声对于胆囊切除术中同期治疗胆道结石决策的价值

目的 观察腹腔镜超声(LUS)用于制定胆囊切除术中同期治疗肝内胆管结石及胆总管结石(CBDS)决策的价值。方法 回顾性分析53例明确诊断胆囊结石(GS)并接受择期腹腔镜下胆囊切除术患者,术中根据LUS所见判断有无肝内胆管结石及CBDS,进而决定是否同期行病变部分肝脏切除术和(或)腹腔镜胆总管探查术(LCBDE)。结果 53例均成功切除胆囊,术中LUS检查胆囊结果与术中及术后所见相同,LUS诊断准确率100%(53/53)。24例术前诊断为单纯GS,其中19例术中LUS诊断与术前相符、5例术中LUS诊断为GS合并CBDS而同期行LCBDE;25例术前诊断为GS合并CBDS,其中23例术中LUS诊断与术前相符而同期行LCBDE,2例术中LUS未发现CBDS、术后影像学复查亦未见CBDS;4例术前诊断GS合并肝内胆管结石,其中3例术中LUS所见与术前相符而行部分肝脏切除,1例术中LUS发现CBDS而行部分肝脏切除术+LCBDE。结论 LUS有助于胆囊切除术中同期治疗肝内胆管结石及CBDS制定决策,可及时完善诊断、调整术式并辅助实施手术。     

多镜联合治疗肝内外胆管结石

目的 探讨腹腔镜、十二指肠镜和胆道镜多镜联合在肝内外胆管结石治疗中的应用价值.方法 回顾性分析2007年4月至2010年8月吉林大学白求恩第一医院收治的316例肝内外胆管结石患者的临床资料.其中胆囊结石合并胆总管结石269例,胆囊结石合并胆总管结石伴肝内胆管结石10例,胆总管结石37例.对于胆总管直径≥10 mm或伴肝内胆管结石的患者行LC+腹腔镜胆总管探查(LCBDE)+胆道镜取石术;对于胆总管直径>5 mm且<10 mm、胆囊管直径<5 mm的患者行EST+LC或LC+EST;对于胆总管直径≤5 mm、胆囊管直径≥5 mm的患者行LC+经胆囊管途径胆总管探查+胆道镜取石术.结果 本组306例患者成功取石,取石成功率为96.8%(306/316).163例行LC+LCBDE+T管引流+胆道镜取石术,平均手术时间为93.6 min,平均住院时间为9.8 d,平均住院费用为2.8万元,5例患者术后出现并发症.54例患者行EST+LC,平均手术时间为45.0 min,平均住院时间为6.6 d,平均住院费用为2.3万元,1例患者术后出现并发症.67例患者行LC+EST,平均手术时间为40.0 min,平均住院时间为6.1 d,平均住院费用为2.4万元,2例患者术后出现并发症.32例患者行胆总管一期缝合及LC+经胆囊管途径胆总管探查+胆道镜取石术.平均手术时间为97.3 min,平均住院时间为7.3 d,平均住院费用2.5万元,1例患者术后出现并发症.272例患者术后平均随访12个月,6例患者术后胆总管结石复发,其余患者未发现残留结石及胆管狭窄.结论 腹腔镜、十二指肠镜和胆道镜三镜联合治疗肝内外胆管结石具有创伤小、恢复快及并发症少的优点.

Abstract：

Objective To investigate the application of laparoscope,duodenoscope and choledochoscope in the treatment of intra-and extrahepatic bile duct stone.Methods The clinical data of 3 16 patients with intraand extrahepatic bile duct stone who were admitted to the Bethune First Hospital from April 2007 to August 2010were retrospectively analyzed.There were 269 patients with cholecystolithiasis and choledocholithiasis,10 patients with cholesystolithiasis,choledocholithiasis and hepatolithiagis,and 37 patients with choledocholithiasis.Laparoscopic cholecystectomy(LC)+laparoscopic common bile duct exploration(LCBDE)+choledochoscopy was applied to patients with hepatolithiasis or with the diameter of common bile duct≥10 mm;endoscopic sphincterotomy (EST)+LC or LC+EST was applied to patients with the diameter of common bile duct between 10 mm and 5 mm and the diameter of cystic duct<5 mm;LC+laparoscopic transcystic common bile duct exploration(TC-CBDE)+choledochoscopy wag applied to patients with the diameter of common bile duct≤5 mm and the diameter of cystic duct≥5 mm.Results The success rate of operation was 96.8%(306/316).A total of 163 patients received LC +LCBDE+T-tube drainage+choledochoscopy,and the mean operation time,expense,duration of hospital stay were 93.6 minutes,2.8×104 yuan and 9.8 days,respectively,and 5 patients had complications postoperatively.Fifty-four patients received EST+LC,and the mean operation time,expense,duration of hospital stay were 45.0minutes,6.6 days,2.3×104yuan,respectively,and 1 patient had complication postoperatively.Sixty-seven patients received LC+EST,and the mean operation time,expense and duration of hospital stay were 40.0minutes,6.1 days,2.4×104 yuan,respectively,and 2 patients had complication postoperatively.Thirty-two patients received one-stage repair of common bile duct and LC+TC-CBDE+choledochoscopy,and the mean operation time,expense and duration of hospital stay were 97.3 minutes,7.3 days and 2.5×104yuan,respectively,and 1 patient had complication postoperatively.A total of 272 patients were followed up for 12 months,except for 6 patients with recurrence of common bile duct stone,no residual stone or biliary stricture was etected.Conclusion Combined application of laparoscope,duodenoscope and choledochoscope has advantages of less trauma,quick ecovery and fewer complications in the treatment of intra-and extrahepatic bile duct stone.     

Clinical models are inaccurate in predicting bile duct stones in situ for patients with gallbladder

Background  The probability that a patient has common bile duct stones (CBDS) is a key factor in determining diagnostic and treatment strategies. This prospective cohort study evaluated the accuracy of clinical models in predicting CBDS for patients who will undergo cholecystectomy for lithiasis. Methods  From October 2005 until September 2006, 335 consecutive patients with symptoms of gallstone disease underwent cholecystectomy. Statistical analysis was performed on prospective patient data obtained at the time of first presentation to the hospital. Demonstrable CBDS at the time of endoscopic retrograde cholangiopancreatography (ERCP) or intraoperative cholangiography (IOC) was considered the gold standard for the presence of CBDS. Results  Common bile duct stones were demonstrated in 53 patients. For 35 patients, ERCP was performed, with successful stone clearance in 24 of 30 patients who had proven CBDS. In 29 patients, IOC showed CBDS, which were managed successfully via laparoscopic common bile duct exploration, with stone extraction at the time of cholecystectomy. Prospective validation of the existing model for CBDS resulted in a predictive accuracy rate of 73%. The new model showed a predictive accuracy rate of 79%. Conclusion  Clinical models are inaccurate in predicting CBDS in patients with cholelithiasis. Management strategies should be based on the local availability of therapeutic expertise.     

Evaluation of laparoscopic management of common bile duct stones in 220 patients

Background: The aim of this study was to evaluate the feasability and results of laparoscopic management of common bile duct stones (CBDS). Methods: From October 1990 to November 1996, 220 patients with CBDS have been managed laparoscopically. CBDS were suspected or diagnosed preoperatively in 130 patients (59.1%) and at intraoperative cholangiography (IOC) in 90 patients (40.9%). A transcystic duct extraction (TCDE) was attempted in 112 patients and a primary choledochotomy in 108 patients. Results: TCDE was successful in 77 cases (68.8%). The 35 failures were treated by 29 laparoscopic choledochotomies, 1 intraoperative and 5 postoperative endoscopic sphincterotomies (ES). A choledochotomy was thus performed in 137 cases and was successful in 133 cases (97.1%). The four failures were managed by three laparotomies and one postoperative ES. The overall success rate was 95.5% (210/220). There was 4 deaths (0.9%) within the 1^st postoperative month in ASA 3 patients and the morbidity rate was 9.1% (20/220). There were 7 residual stones (3.2%). Conclusions: Laparoscopic desobstruction of CBDS appears to be safe and effective and has the advantage to be a single-stage procedure. It could become in the future with refinement of instrumentation and skill of surgeons the best treatment for the majority of patients harboring CBDS. Received: 8 December 1996/Accepted: 14 February 1997     

Laparoscopic common bile duct exploration

OBJECTIVE: To describe the technique of laparoscopic common bile duct exploration (LCBDE) with high clearance rates, low morbidity, and mortality rates. SUMMARY BACKGROUND DATA: LCBDE is well accepted by patients because treatment is obtained during the same anesthesia. If one stage therapy for gallstones and common bile duct stones provides success rates equivalent to those of the sequential approach, with lower costs, this should be considered the standard of care. METHODS: From September 1991 to March 2007, 5201 laparoscopic cholecystectomies were performed at S?o José Avaí Hospital. LCBDE was carried out in 481 patients (9.25%). RESULTS: Of 481 LCBDE, 225 (46.78%) were managed using a transcystic approach and 183 (38.05%) with choledochotomy (114 with transcystic choledochotomy and 69 with longitudinal opening of the common bile duct). Successful laparoscopic stone clearance was achieved in 468 (97.3%). An elective postsurgical endoscopic sphincterotomy were done on the 13 (2.70%) patients not cleared laparoscopically. Seven patients had unexpected retained stones. CONCLUSIONS: LCBDE during laparoscopic cholecystectomy solves 2 problems during the same anesthesia with high success rates and may be employed successfully.     

两种微创治疗方案治疗老年患者胆总管结石的临床对照研究

目的比较腹腔镜胆囊切除联合胆总管探查术（LC联合LCBDE）与内镜乳头切开取石联合腹腔镜胆囊切除术（EST联合LC）治疗老年患者（≥65岁）胆总管结石的临床疗效。方法2005年7月～2010年12月,胆总管直径≥8mm且既往未接受乳头括约肌切开、胆囊切除或胆道手术的110例老年胆总管结石患者,LC联合LCBDE组47例,先行LC,确认胆总管后行LCBDE,结石取净后胆道镜检查胆道系统以确认有无结石残留;EST联合LC组63例,十二指肠镜确认十二指肠乳头,常规ERCP进一步明确诊断后行EST,取石后鼻胆管引流2—5d后行LC。对两组结石清除率、术后并发症、中转开腹率及单次治疗成功率等指标进行对比,并进行随访。结果2组结石清除率、术后并发症、中转开腹率差异无显著性（P〉0．05）,而单次治疗成功率Lc联合LCBDE组显著高于EST联合LC组[87．2％（41／47）vs．68．3％（43／63）,z。=5．372,P=0．020]。所有病例随访1—3年,平均2．1年,未出现腹痛、发热及黄疸等症状,B超未见结石复发。结论LC联合LCBDE和EST联合LC都是治疗老年患者胆总管结石安全有效的方法,而在减少治疗次数方面,LC联合LCBDE更有优势。     

自制腹腔镜胆道冲洗器在腹腔镜胆总管取石术中的应用：双中心经验总结

背景与目的 腹腔镜胆总管探查取石术（LCBDE）是治疗胆总管结石的主要治疗方式,但在LCBDE过程中,由于术中缺少窦道支撑,经典的胆道镜下网篮取石相对较为困难,对术者的操作技术要求高,反复的胆道镜取石也容易造成胆道镜损坏或胆管壁损伤。为了更好地提高取石效率,降低手术难度,笔者对胆道镜取石术进行改良,即LCBDE术中采用自制腹腔镜胆道冲洗器配合胆道镜取石。本研究总结两个中心应用该方法的临床效果。方法 回顾2017年1月—2021年1月福建省立医院和福建省浦城县医院收治的313例LCBDE术中应用自制腹腔镜胆道冲洗器治疗的胆总管结石患者的临床资料,分析患者围手术期情况及近期预后。结果 313例患者中,男132例,女181例;平均年龄（56.3±13.2）岁;173例患者为胆总管单发结石,140例患者为胆总管多发结石（结石最多者为10枚）;中位结石直径为0.5（0.2~3.1） cm,中位胆总管直径为1.2（0.6~3.3）cm。手术均顺利完成,无中转开腹。其中281例（89.8%）患者使用自制腹腔镜胆道冲洗器取净结石,32例（10.2%）患者术中联合网篮取石。307例（98.1%）患者一期取净结石,6例（1.9%）患者残留结石;157例（50.2%）术后一期缝合胆总管,156例（49.8%）术后留置T管引流。平均手术时间（109.3±29.4）min,平均术中出血量（42.5±8.4）mL,平均术后住院时间（7.6±3.2）d。术后12例出现胆汁漏,12例出现腹腔感染,9例出现肺部感染,7例出现切口感染,1例出现术后出血,均经保守治疗后痊愈。6例无法一期取净结石患者均于术后1.5个月行经T管窦道胆道镜取净结石。术后随访6~12个月,无胆管结石复发、胆道狭窄等其他并发症。结论 LCBDE术中应用自制腹腔镜胆道冲洗器安全可靠,取石效率高,故推荐使用。     

腹腔镜胆总管切开探查取石、T管引流治疗胆总管结石

目的 探讨腹腔镜胆总管切开探查、T管引流治疗胆总管结石的疗效。方法 配合使用胆道镜施行胆总管切开探查105例,并采用镜下缝合和打结技术常规安置T管。结果 2例胆总管探查为阴性,102例结石取净、净石率99．0％（102／103）。结论 胆总管切开探查取石、T管引流是治疗胆总管结石的安全、有效措施,可根据条件选择应用。     

Comparison of emergent versus elective laparoscopic common bile duct exploration for patients with or without nonsevere acute cholangitis complicated with common bile duct stones

Background

Laparoscopic common bile duct exploration (LCBDE) has already been established for the treatment of patients with common bile duct stones (CBDS) in elective situations. However, the effect of emergent LCBDE on those patients with nonsevere acute cholangitis has not been assessed. The aim of this study was to evaluate the effect of emergent LCBDE on patients with nonsevere acute cholangitis complicated with CBDS.

Methods

Seventy-two patients with CBDS admitted from January 2009 to December 2012 were included for this retrospective study. LCBDE of transductal approach for CBDS was performed to all patients. Thirty-seven patients underwent emergent LCBDE for nonsevere acute cholangitis and 35 patients underwent elective LCBDE. Duration of the procedure, complications, retained stone of bile duct, hospital stay, and total charges were compared between the two groups. In addition, the characteristics of patients underwent emergent LCBDE were also compared before and after surgery.

Results

There was no significant difference with regard to the diameter of common bile duct and number of CBDS from imaging and/or operative findings between the two groups. There was no conversion to open common bile duct exploration, no major bile duct injuries, and no mortality in both the group of patients. There was no significant difference in patients with or without acute or chronic cholecystitis, duration of surgery, overall hospital stay (16.41 ± 1.03 versus 14.54 ± 0.94, P > 0.05), and total charges (18,603 ± 1774.64 versus 14,951 ± 1257.09 Yuan in renminbi, P > 0.05) between the two groups. Four cases with retained stones were found in patients with emergent LCBDE and two in elective LCBDE patients. There were four cases of biliary leak in patients with emergent LCBDE and three cases in elective LCBDE group, respectively. However, there was no statistical difference between the two groups. The biliary leak was cured postoperatively after drainage. Control of septic symptoms was achieved in all patients after emergent LCBDE.

Conclusions

Our data indicated that emergent LCBDE is as safe and effective as elective LCBDE for the treatment of patients with nonsevere acute cholangitis complicated with CBDS.     

Long-term results from laparoscopic common bile duct exploration

Background: The aim of this study was to evaluate the long-term results after laparoscopic common bile duct exploration (LCBDE). Methods: A retrospective review of 175 consecutive patients who underwent attempted LCBDE between 1992 and 1999 was conducted. Laparoscopic transcystic exploration was accomplished in 110 patients and laparoscopic choledochotomy in 52 patients. Conversion to an open common bile duct exploration was required for 13 patients (7.4%). Retained common bile duct stones occurred in eight patients (4.6%). The 30-day postoperative morbidity was 6.9%, and there was no 30-day mortality. All the patients (alive and localized) received a questionnaire evaluating long-term results. Results: Of the 175 patients, 169 (4 unrelated deaths and 2 patients lost to follow-up evaluation) received and 152 (90%) returned the questionnaire. The follow-up period ranged from 6 to 72 months (median, 36 months). One patient developed recurrent common bile duct stones. There were no signs or evidence of common bile duct stricture in any patient. Conclusion: The LCBDE procedure can be performed without increased risk of late bile duct complications.     

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.     

Evaluation of laparoscopic treatment of common bile duct stones in a prospective series of 505 patients: indications and results

BACKGROUND: The aim of this prospective study was the evaluation of the laparoscopic treatment of common bile duct stones (CBDS) and its indications. METHODS: Five hundred five patients who underwent laparoscopic treatment of CBDS from October 1990 to September 2006 were included in the prospective study. The mean age of the patients was 63 years (range = 19-93). Four hundred fifteen patients were classified ASA I and ASA II and 90 were ASA III and ASA IV. CBDS were suspected or diagnosed preoperatively in 373 patients (73.8%) and diagnosed at intraoperative cholangiography (IOC) in 132 patients (26.2%). A transcystic duct extraction (TCDE) was attempted in 254 patients (50.4%) and a primary choledochotomy in 251 patients (49.6%). Biliary drainage after choledochotomy was used in 148 cases (48.8%). RESULTS: TCDE was successful in 191 cases (75.2%).The 63 failures were managed by laparoscopic choledochotomy in 53 cases and by endoscopic sphincterotomy (ES) in 10 cases. A choledochotomy was thus performed in 304 patients and successful in 295 cases (97%). The nine failures were managed by six conversions to laparotomy (2%) and three postoperative ES. The overall success rate was 96.2%. The morbidity rate was 7.9% with 4.8% of local complications and 3.1% of general complications. The mortality rate was 1%. There were 14 residual stones (2.8%) that were managed by a second laparoscopy in two cases and by ES in 12 cases with four failures managed by laparotomy in one case and laparoscopy in three cases. CONCLUSION: Laparoscopic management of CBDS was effective in more than 96% of cases and particularly safe in ASA I and ASA II patients. It has the advantage over ES followed by laparoscopic cholecystectomy (LS) to be a one-stage procedure.     

腹腔镜胆总管探查术中细纤维胆道镜的应用

4例胆囊结石的病人在行腹腔镜胆囊切除术中行胆道造影并经细纤维胆道镜经胆囊管扩取石。2例经造影证实为胆总管下端结石,1例取石成功,另1例因结石较大而致使取石失败,后经内镜乳头括约肌切开取石成功。1例造影怀疑胆总管下端结石,术中镜检正常。1例切开胆囊管冲洗泥沙样结石并取石成功。LC术中采用细纤维胆道镜检查并取石是一安全有效的手段。