Efficacy and safety of laparoscopic common bile duct exploration with primary closure and intraoperative endoscopic nasobiliary drainage for choledocholithiasis combined with cholecystolithiasis.

BACKGROUND: The need for intraoperative endoscopic nasobiliary drainage during laparoscopic cholecystectomy and laparoscopic common bile duct exploration with primary closure is controversial in the treatment of cholecystolithiasis combined with choledocholithiasis. The aim of this study was to evaluate the safety and efficacy of laparoscopic cholecystectomy + laparoscopic common bile duct exploration + intraoperative endoscopic nasobiliary drainage + primary closure (LC + LCBDE + IO-ENBD + PC). The safety of different intubation methods in IO-ENBD was also evaluated. METHOD: From January 2018 to January 2022, 168 consecutive patients with cholecystolithiasis combined with choledocholithiasis underwent surgical treatment in our institution. Patients were divided into two groups: group A (n = 96) underwent LC + LCBDE + IO-ENBD + PC and group B (n = 72) underwent LC + LCBDE + PC. Patient characteristics, perioperative indicators, complications, stone residual, and recurrence rates were analyzed. Group A was divided into two subgroups. In group A1, the nasobiliary drainage tube was placed in an anterograde way, and in group A2, nasobiliary drainage tube was placed in an anterograde-retrograde way. Perioperative indicators and complications were analyzed between subgroups. RESULTS: No mortality in the two groups. The operation success rates in groups A and B were 97.9% (94/96) and 100% (72/72), respectively. In group A, two patients were converted to T-tube drainage. The stone clearance rates of group A and group B were 100% (96/96) and 98.6% (71/72), respectively. Common bile duct diameter was smaller in group A [10 vs. 12 mm, P < 0.001] in baseline data. In perioperative indicators, group A had a longer operation time [165 vs.135 min, P < 0.001], but group A had a shorter hospitalization time [10 vs.13 days, P = 0.002]. The overall complications were 7.3% (7/96) in group A and 12.5% (9/72) in group B. Postoperative bile leakage was less in group A [0% (0/96) vs. 5.6% (4/72), P = 0.032)]. There were no residual and recurrent stones in group A. And there were one residual stone and one recurrent stone in group B (all 1.4%). The median follow-up time was 12 months in group A and 6 months in group B. During the follow-up period, 2 (2.8%) patients in group B had a mild biliary stricture. At subgroup analysis, group A1 had shorter operation time [150 vs. 182.5 min, P < 0.001], shorter hospitalization time [9 vs. 10 days, P = 0.002], and fewer patients with postoperative elevated pancreatic enzymes [32.6% (15/46) vs. 68% (34/50), P = 0.001]. CONCLUSION: LC + LCBDE + IO-ENBD + PC is safer and more effective than LC + LCBDE + PC because it reduces hospitalization time and avoids postoperative bile leakage. In the IO-ENBD procedure, the antegrade placement of the nasobiliary drainage tube is more feasible and effective because it reduces the operation time and hospitalization time, and also reduces injury to the duodenal papilla.

Value of multidisciplinary team (MDT) in minimally invasive treatment of complex intrahepatic bile duct stones.

This study aimed to investigate the value of multidisciplinary team (MDT) management in minimally invasive treatment of complex intrahepatic bile duct stones (IHDs) by laparoscopy, choledochoscopy and percutaneous choledochoscopy. The characteristics, perioperative index, complication rate and minimally invasive rate of patients in MDT group (n = 75) and non-MDT group (n = 70) were compared. The members of MDT include doctors in ultrasound, imaging, hepatobiliary and pancreatic surgery, anaesthesia and intensive care medicine. The results showed that minimally invasive surgery reduced the incidence of postoperative residual stones, OR (95% CI) = 0.365 (0.141-0.940) (p = 0.037). MDT reduced the operation time, OR (95% CI) = 0.406 (0.207-0.796) (p = 0.009). Minimally invasive surgery significantly reduced intraoperative bleeding, OR (95% CI) = 0.267 (0.133-0.534) (p < 0.001). Minimally invasive surgery also reduced hospitalization time, OR (95% CI) = 0.295 (0.142-0.611) (p = 0.001). The stone clearance rates of MDT group and non-MDT group were 81.33% and 81.43% respectively. In the MDT group, the operative time was less than that in the non-MDT group (p = 0.010); the intraoperative bleeding volume was significantly less than that in the non-MDT group (p < 0.001); the hospitalization time was less than that in the non-MDT group (p = 0.001). Minimally invasive operation rate:48 cases (64.00%) in MDT group were significantly higher than 17 cases (24.29%) in non-MDT group (p < 0.001). In conclusion, minimally invasive procedures can be selected more through MDT. MDT can shorten the operation time, and minimally invasive surgery can reduce the incidence of residual stones, reduce intraoperative bleeding, and may shorten hospital stay. Therefore, MDT management model can provide personalized and minimally invasive surgical protocol for patients with complex IHD, which has high application value.