Curative surgical treatment of common bile duct stones: Retrospective cohort study.

BACKGROUND: In the event of symptomatic common bile duct (CBD) stones with dilated CBD, one possible curative treatment option is stone extraction through choledocotomy associated with cholecystectomy. Endoscopic treatment is only reserved for residual stones at 6 weeks. The aim of this study was to evaluate the results from laparoscopic curative surgical treatment of CBD stones with dilated CBD. METHODS: This is a retrospective single-centered cohort study. All consecutive patients admitted for laparoscopic cholecystectomy with evidence of CBD stones with dilated CBD from January 2010 to December 2020 at our center were included. Success was defined by CBD clearance at 6 weeks. Need for additional procedures, such as endoscopic sphincterotomy, immediate, and end-of-procedure morbi-mortality as well as factors associated with procedure failure, were also studied. RESULTS: A total of 246 patients who received curative treatment were included in the study. The success rate for the curative treatment was 93.1% (229 patients). Immediate postoperative morbidity was 24.4% with a 5.3% reintervention rate. Immediate and 6-week postoperative mortality rates were zero and 0.4%, respectively. The mean length of stay was 11.3 days. Factors associated with procedure failure appeared to be the occurrence of an early postoperative complication and the need for readmission during the period between surgery and drain removal. CONCLUSION: This study indicates that laparoscopic curative surgical treatment for symptomatic CBD stones may be performed with acceptable results without routine need for additional procedures.

T-tube implantation combined with cricoid cartilage reconstruction in the treatment of congenital laryngeal webs with subglottic stenosis.

OBJECTIVE: To discuss the presentation, evaluation, and management of congenital laryngeal webs with subglottic stenosis. METHODS: The clinical data of six children were retrospectively analyzed. RESULTS: The median age of these children who came to our hospital was 14 months (range 1-26 months). A tracheotomy was performed in all these six children. The median age of the patients who underwent tracheotomy was 4 months (range 1-11 months). The surgical method was T-tube implantation combined with cricoid cartilage reconstruction. The median age of these patients at the time of operation was 22 months (range 13-35 months). The T-tube remained in place for 3-8 months, with a median time of 6 months. The tracheal tubes in all these children were successfully removed. All patients were followed up for more than 2 years without recurrence. CONCLUSIONS: Children who have congenital laryngeal webs with subglottic stenosis required early tracheotomy. Open laryngoplasty combined with T-tube implantation and cricoid cartilage reconstruction may play a crucial role in the treatment of these children.

Residual choledocholithiasis after choledocholithotomy T-tube drainage: what is the best intervention strategy?

BACKGROUND: The best intervention approach for residual choledocholithiasis after choledocholithotomy T-tube drainage remains controversial, especially during the period of indwelling T tube and the formation of a sinus. The purpose of the study was to estimate the effects of two therapeutic modalities, namely endoscopic retrograde cholangiopancreatography (ERCP) and choledochfiberscope via the T-tube sinus tract (CDS) on residual choledocholithiasis after choledocholithotomy T-tube drainage. METHODS: A total of 112 patients with residual choledocholithiasis after choledochotomy were included in the study, 50 of which underwent ERCP and 62 patients experienced choledochoscopy via the T-tube sinus tract. The primary outcome measures included the success rate of remove biliary stones, T-tube drainage time, and the average length of hospital stay. The secondary objective was to consider incidence of adverse events including cholangitis, bile leakage, T-tube migration, pancreatitis, bleeding and perforation. After hospital discharge, patients were followed up for two years and the recurrence of choledocholithiasis was recorded. RESULTS: There was no significant difference in the success rate of stone removal between the two groups. Compared to CDS group, T-tube drainage time and the average length of hospital stay was significantly shorter in the ERCP group. The incidence of complications (cholangitis and bile leakage) in the ERCP group was lower than that in the CDS group, but there was no statistically significant difference. When the T-tube sinus tract is not maturation, ERCP was the more appropriate endoscopic intervention to remove residual choledocholithiasis, particularly complicated with cholangitis at this time period. CONCLUSIONS: ERCP is a safe and effective endoscopic intervention to remove residual choledocholithiasis after choledocholithotomy T-tube Drainage without the condition of T-tube sinus tract restriction.

Comparative study of three common bile duct closure techniques after choledocholithotomy: safety and efficacy.

PURPOSE: T-tube drainage, primary closure, and biliary stenting are the common bile duct closure methods. There is great debate on the optimal duct closure technique after common bile duct exploration. This study aimed to assess the safety and efficacy of the three commonest common bile duct closure methods after common bile duct exploration for common bile duct stone for future generalization. METHODS: In this analysis, 211 patients with common bile duct stone underwent common bile duct exploration from January 2016 to December 2020. The patients were divided according to common bile duct closure techniques into three groups, including the T-tube drainage group (63 patients), primary duct closure group (61 patients), and antegrade biliary stenting group (87 patients). RESULTS: The incidence of overall biliary complications and bile leak were statistically significantly lower in the biliary stenting group than in the other two groups. Also, hospital stays, drain carried time, return to normal activity, re-intervention, and re-admission rates were statistically significantly lower in the biliary stenting group than in the other two groups. There were no statistically significant differences regarding operative and choledochotomy time, retained and recurrent stone, stricture, biliary peritonitis, cholangitis, and the cost among the three groups. CONCLUSIONS: We state that the biliary stenting procedure should be the preferred first option for common bile duct closure after common bile duct exploration when compared with T-tube drainage and primary duct closure. TRIAL REGISTRATION: ClinicalTrials.gov PRS (Approval No. NCT04264299).

Emergency Airway Management in a Patient with a T-Tube Tracheal Stent.

BACKGROUND: Abnormal anatomy complicates emergency airway management. In this case, we describe definitive airway management in a critically injured emergency department (ED) patient with a history of partial tracheal resection who had a Montgomery T-tube, a type of T-shaped tracheal stent, in place at the time of the motor vehicle collision. The Montgomery T-tube is not a useful artificial airway during resuscitation, as it lacks a cuff or the necessary adapter for positive pressure ventilation. CASE REPORT: We describe a case of a 51-year-old man who required emergency airway management after a motor vehicle collision. The patient had a Montgomery T-tube in place, which was removed with facilitation by ketamine sedation and topical anesthesia. The patient was successfully intubated through the tracheal stoma after removal of the T-tube. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians must recognize the Montgomery T-tube, which resembles a standard tracheostomy tube externally, and have some understanding of how to manage a critically ill patient with this rare device in place. When a patient with a Montgomery T-tube in place requires positive pressure ventilation, the device may require emergent removal and replacement with a cuffed tracheostomy or endotracheal tube.

Laparoscopic common bile duct exploration after failed endoscopic retrograde cholangio-pancreatography: Our patient series over a period of 10 years.

Aim: Laparoscopic CBD exploration (LCBDE) for Common bile duct (CBD) stones with laparoscopic cholecystectomy (LC) is an alternative to open CBD exploration, in patients with failed endoscopic retrograde cholangio-pancreatography (ERCP). It is being performed at few centres with adequate surgical expertise. Herein, we present our experience of LCBDE with LC over a period of 10 years. Patients and Methods: A retrospective analysis of prospectively recorded data of 121 consecutive patients was performed from February 2010 to November 2019, who underwent LC and LCBDE by choledochotomy in a single surgical unit. These included all patients with failed pre-operative ERCP. Results: Out of 121 patients, LCBDE successfully cleared the CBD in 118, and three patients were converted to open surgery. All these patients underwent choledochotomy for adequate exploration of CBD. T-tube closure of CBD was performed in 103 patients and removed after a mean of 14.6 ± 2.4 days. Primary closure was performed in 15 patients. The mean hospital stay post-procedure was 3.4 ± 0.7 days. Complete ductal clearance was achieved in 115 patients, and residual stone fragments reported in three patients were removed by ERCP. None of the patients experienced biliary peritonitis, biliary fistula, pancreatitis or cholangitis. There was no 30-day mortality and no recurrent stones reported with a mean follow-up of 12.4 ± 3.9 months. Conclusion: With adequate surgical expertise, LCBDE is a feasible alternative to open surgery for CBD stones after failed ERCP with early recovery and low morbidity.

Association of weaning failure from mechanical ventilation with transthoracic echocardiography parameters: a systematic review and meta-analysis.

BACKGROUND: Weaning from mechanical ventilation is a challenging step during recovery from critical illness. Weaning failure or early reintubation are associated with increased morbidity and mortality, exposing patients to life-threatening complications. Cardiac dysfunction represents the most common cause of weaning failure. We conducted a systematic review and meta-analysis to evaluate the association between transthoracic echocardiographic parameters and weaning failure. METHODS: We performed a systematic search of MEDLINE and EMBASE screening for prospective studies providing echocardiographic data collected just before the beginning of spontaneous breathing trial and outcome of the weaning attempt. We primarily focused on parameters currently recommended for evaluation of left ventricular (LV) systolic or diastolic dysfunction. RESULTS: We included 11 studies in our primary analysis, which included data on LV ejection fraction (LVEF, n=10 studies) and parameters recommended for the assessment of LV diastolic function (E/e' ratio n=10; E/A ratio n=9; E wave n=8; and e' wave n=7). Weaning failure was significantly associated to a higher E/e' ratio (standardised mean difference [SMD]=1.70, 95% confidence interval [CI; 0.78-2.62]; P<0.001), lower e' wave (SMD=-1.22, 95% CI [-2.33 to -0.11]; P=0.03), and higher E wave (SMD=0.97, 95% CI [0.29-1.65]; P=0.005). We found no association between weaning failure and LVEF (SMD=-0.86, 95% CI [-1.92-0.20]; P=0.11) and E/A ratio (SMD=0.00, 95% CI [-0.30-0.31]; P=0.98). CONCLUSIONS: Weaning failure is associated with parameters indicating worse LV diastolic function (E/e', e' wave, E wave) and increased LV filling pressure (E/e' ratio). The association between weaning failure and LV systolic dysfunction as evaluated by LVEF is more unclear. More studies are needed to clarify this aspect and regarding the role of right ventricular function.

T tube sinus tract duodenal fistula: a rare complication of postoperative choledochoscopy for treating retained intrahepatic stones.

BACKGROUNDS: Postoperative percutaneous choledochoscopy via T tube sinus tract is a common modality for treating retained intrahepatic stones in China. We report a rare complication of postoperative choledochoscopy for treating retained hepatolithiasis: T tube sinus tract duodenal fistula. METHODS: From January 2003 to December 2018, intrahepatic duct stones with or without common bile duct stones were detected in 1031 patients. Fifteen of the 1031 patients with intrahepatic stones developed a T tube sinus tract duodenal fistula that was diagnosed by cholangiography and choledochoscopy. RESULTS: The incidence of T tube sinus tract duodenal fistula in patients with retained intrahepatic stones being treated by postoperative choledochoscopy is 1.45% (15/1031) in this series. The chi-squared test showed that hypoalbuminemia (P = 0.003), long duration of T tube (P = 0.002), and high frequency of procedure (P = 0.008) might be associated with the occurrence of T tube sinus tract duodenal fistula. The logistic regression analysis demonstrated that hypoalbuminemia might be the independent risk factor for this special fistula (P = 0.037). CONCLUSIONS: Hypoalbuminemia, long time placement of T tube in situ and high frequency of procedure are probably the main causes of the T tube sinus tract duodenal fistula. Placement of T tube in correct way and improving nutritional status may be the key points to prevent the formation of T tube sinus tract duodenal fistula.

Double versus single T-tube drainage for frank cysto-biliary communication in patients with hepatic cystic echinococcosis: a retrospective cohort study with median 11 years follow-up.

BACKGROUND: Partial peri-cystectomy (PPC) is one of the major surgical approaches for hepatic cystic echinococcosis (CE) and has been practiced in most centers worldwide. Cysto-biliary communication (fistula, leakage, rupture) is a problematic issue in CE patients. T-tube is a useful technique in situations where an exploration and decompression are needed for common bile duct (CBD). However, postoperative biliary complications for cystic cavity still remains to be studied in depth. METHODS: A retrospective cohort analysis of CE cases in our single center database from 2007 March to 2012 December was performed. Patients (n = 51) were divided into two cohorts: double T-tube drainage (one at CBD for decompression and one at the fistula for sustaining in cystic cavity, n = 23) group and single T-tube drainage cohort (only one at CBD for decompression, n = 28). Short-/long-term postoperative complications focusing on biliary system was recorded in detail and they were followed-up for median 11 years. RESULTS: Overall biliary complication rates for double and single T-tube drainages were 17.4% vs. 39.3% (P > 0.05). Short-term complications ranged from minor to major leakages, cavity infection and abscess formation, and prevalence was 17.4% vs. 21.4% (P > 0.05) respectively for double and single T-tube groups; most importantly, double T-tube drainage group had obvious advantages regarding long-term complications (P < 0.05), which was biliary stricture needing surgery and it was observed only in single T-tube drainage group. CONCLUSIONS: Double T-tube drainage had better outcomes without procedure-specific postoperative biliary complications than single T-tube drainage. Meanwhile, we recommend long-term follow-up when comparing residual cavity related biliary complications in CE patients as it could happen lately.

Can T-tube drainage be replaced by primary suture technique in laparoscopic common bile duct exploration? A meta-analysis of randomized controlled trials.

BACKGROUND: Although laparoscopic common bile duct exploration (LCBDE) is considered the best treatment and has the advantages of being minimally invasive for common bile duct (CBD) stones, the choice of T-tube drainage (TTD) or primary duct closure (PDC) after LCBDE is still controversial. Therefore, the aim of the study was to compare the superiority of PDC versus TTD after LCBDE for choledocholithiasis. METHODS: All potential studies which compare the surgical effects between PDC with TTD were electronically searched for in PubMed, Web of Science, and the Cochrane library databases up to November 2019. Data synthesis and statistical analysis were carried out using RevMan 5.3 software. RESULTS: In total, six randomized controlled trials with 604 patients (307 in the PDC group and 297 in the TTD group) were included in the current meta-analysis. As compared with the TTD group, the pooled data showed that PDC group had shorter operating time (WMD = -24.30; 95% CI = -27.02 to -21.59; p < 0.00001; I2 = 0%; p < 0.88), less medical expenditure (WMD = -2255.73; 95% CI = -3330.59 to -1180.86; p < 0.0001; I2 = 96%; p < 0.00001), shorter postoperative hospital stay (OR = -2.88; 95% CI = -3.22 to -2.54; p < 0.00001; I2 = 60%; p < 0.03), and lower postoperative complications (OR = 0.49; 95% CI = 0.31 to 0.78; p = 0.77; I2 = 0%; p = 0.003). There were no significant differences between the two groups concerning bile leakage (OR = 0.74; 95% CI = 0.36 to 1.53; p = 0.42; I2 = 0%; p = 0.90) and retained stones (OR = 0.96; 95% CI = 0.36 to 2.52; p < 0.93; I2 = 0%; p < 0.66). CONCLUSIONS: LCBDE with PDC should be performed as a priority alternative compared with TTD for choledocholithiasis.

Electrical impedance tomography monitoring during spontaneous breathing trial: Physiological description and potential clinical utility.

BACKGROUND: Readiness for mechanical ventilation (MecV) weaning and extubation is usually assessed clinically with the use of a spontaneous breathing trial (SBT), but its accuracy is limited, and the pathophysiology of weaning failure not completely elucidated. The purpose of the present study was to describe the physiological behavior of electrical impedance tomography parameters during SBT and to propose additional variables that could be helpful in defining weaning/extubation outcome. METHODS: From December 2015 to January 2017, all subjects who remained under MecV with an orotracheal tube for more than 24 hours and who were submitted to SBT both in pressure-support ventilation (PSV) or T-tube were included in the study. Both clinical and impedance parameters were collected immediately before as well as during SBT. RESULTS: Forty-two subjects were included in the final analysis. For subjects submitted to SBT in PSV, none of the impedance parameters added significant information regarding weaning outcomes. For subjects submitted to a T-tube SBT, a significant and progressive decrease in end-expiratory lung impedance (dEELI) was observed, which was more prominent in subjects who clinically failed the SBT. These subjects had a significant rapid shallow breathing index at the end of SBT. CONCLUSIONS: dEELI was a potentially useful parameter in the evaluation of MecV weaning outcome when abrupt lung depressurization was induced during SBT in our study. The degree of dEELI decrease was probably related to the magnitude of lung derecruitment, which seems to play a key role in the MecV weaning outcome.

Routine guidewire application facilitates cholangioscopy in the management of postoperative residual hepatolithiasis.

BACKGROUND AND AIM: Although postoperative cholangioscopy (POC) is considered to be an effective treatment for residual hepatolithiasis after surgery, its security and validity still need to be improved. This study compared wire-guided POC (WG-POC) versus traditional POC (T-POC) in the management of patients with residual hepatolithiasis. METHODS: This retrospective study included a total of 203 patients who suffered from hepatolithiasis and underwent hepatectomy as initial intervention from 1 January 2016 to 1 January 2017. After surgery, 110 patients were subjected to T-POC and 93 to WG-POC for eliminating residual hepatolithiasis. Perioperative course and follow-up outcomes were retrospectively analyzed. RESULTS: No significant differences in clinical characteristics or distribution of residual hepatolithiasis between the WG-POC and T-POC groups were observed (P > 0.05). However, overall POC interventional sessions (2.9 ± 0.85 vs 4.0 ± 1.21 times), average operating time (264.8 ± 103.61 vs 389.4 ± 136.26 min), overall complications rate (18.28% vs 32.73%), and overall T-tube retaining time (21.8 ± 6.20 vs 28.8 ± 8.09 days) were lower in the WG-POC group than in the T-POC group (P < 0.05). In addition, there were no significant differences between the two groups (WG-POC vs T-POC) in recurrence (4.30% vs 4.55%) and residual calculi (8.60% vs 6.36%) at half-a-year follow up (P > 0.05). CONCLUSIONS: Routine wire guidance may improve the outcome of cholangioscopy in managing complicated residual hepatolithiasis, being associated with clear advantages such as shorter operating time and number of POC interventions, reduced T-tube retaining time, and fewer postoperative complications.

Anterior-posterior cricoid split combined with silastic T-tube stenting for subglottic stenosis in children: a single surgeon's experience.

PURPOSE: Treatment strategies and clinical outcomes of subglottic stenosis (SGS) in children are varied due to the degree and range of stenotic lesions. The optimal surgical procedure for SGS in children is still under debate. The aim of this study was to evaluate the clinical outcomes of our anterior-posterior cricoid (APC) split technique combined with long-term T-tube stenting for grade II or III SGS in children. METHODS: A retrospective chart review of children with SGS between January 2011 and December 2016 was conducted. APC split was performed via open procedure under rigid bronchoscopy. After splitting, a silastic T-tube was inserted as a stent and removed 6 months postoperatively. RESULTS: Seven children underwent APC split during the period. All children had undergone previous tracheostomy, and APC split was performed when the children were 3-9 years old without any intraoperative complications. Median duration of T-tube stenting was 11 months, and all children were decannulated successfully. There were T-tube-related complications, including two tube-tip granulation that required intervention and one accidental T-tube removal. CONCLUSION: APC split is a technically simple and reproducible procedure, and it could be employed as an optimal procedure for SGS in children.

Should Children With Cleft Palate Receive Early Long-Term Tympanostomy Tubes: One Institution's Experience.

OBJECTIVES: To determine whether children with cleft palate might benefit from early long-term tympanostomy tubes with the hypothesis that receiving multiple tubes is associated with shorter duration of first tubes. DESIGN: Retrospective cohort study. SETTING: Tertiary care children's hospital. PARTICIPANTS: Records from 401 consecutive children with cleft palate ± cleft lip, born April 2005 to April 2010, were reviewed. After exclusion of children with cleft repair at an outside hospital, no follow-up after 5 years of age, intact secondary palate, no tubes, or tube replacement at palatoplasty, 105 children remained. MAIN OUTCOME MEASURE: Number of tubes. RESULTS: Armstrong grommet tubes were placed at a median age of 6.7 months (range 2.3-19.6 months). Tubes were replaced in 55.3% of patients, with 34.0% receiving ≥3 sets. Duration of first tubes was significantly longer for children with 1 set of tubes compared with those with multiple sets (median 26 vs 19 months, P = .004). Otorrhea, but not perforation, was associated with longer duration of first tubes (median 27 vs 20.5 months, P = .028). Cleft type did not impact the proportion of patients with multiple tubes. Median age at last tube placement for children with multiple tubes was 5.0 years (range 1.9-8.7 years). CONCLUSION: Short duration of first tubes is associated with receiving multiple tubes. Because most patients require repeat tubes and many require tubes until school age, there is a significant need for controlled, prospective trials of early long-term tube placement in this population.

Appropriate Patient Selection Is Essential for the Success of Primary Closure After Laparoscopic Common Bile Duct Exploration.

BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) is being increasingly used for management of common bile duct (CBD) stones. Primary CBD closure has been reported to have better short-term outcomes compared to T-tube placement. However, primary CBD closure cannot be performed in all patients. AIM: This study aims to evaluate the short- and long-term outcomes of LCBDE with primary CBD closure in appropriately selected patients and compare them with T-tube drainage. METHODS: Retrospective analysis of patients undergoing LCBDE in our department from June 2011 to October 2014 was performed. Primary closure was performed in 52 patients (group A), and a T-tube was placed in 33 patients (group B). Patient demographics, intraoperative findings, postoperative stay, complications, and long-term follow-up data were recorded and compared. RESULTS: The mean operating time was much longer in group A compared to group B (113.92 vs. 95.92 min, p = 0.032). The overall complication rate (9.6 vs. 6.3%, p = 0.701) and hospital stay (4 vs. 5.11 days, p = 0.088) were similar in both groups. No patient required conversion to the open procedure. Bile leakage was more frequent in group A (5.78 vs. 0%, p = 0.279), but this was not statistically significant. All three patients with bile leakage were treated successfully by conservative measures and gradual drain withdrawal. On long-term follow-up, recurrent stones were detected in two patients in group A. No patient was found to develop CBD stricture. CONCLUSION: LCBDE and primary CBD closure has excellent short- and long-term outcomes when performed in appropriately selected patients.

Blood in the T-tube as a side effect of hemosuccus pancreaticus.

This study examined a 60-year-old female patient with chronic pancreatitis and hemosuccus pancreaticus (HP), who was once misdiagnosed with biliary bleeding because of choledocholithiasis and T-tube drainage. Bleeding from the T-tube was demonstrated as a side effect of HP. The difficulty in diagnosing this case was attributed to the absence of pseudocysts or obvious aneurysms on CT images. Conclusively, for patients with indirect signs of biliary bleeding, such as bleeding from a T-tube, the possibility of the symptoms being side effects of pancreatic bleeding should be considered.

Systematic review with meta-analysis of studies comparing primary duct closure and T-tube drainage after laparoscopic common bile duct exploration for choledocholithiasis.

BACKGROUND: With advances in laparoscopic instrumentation and acquisition of advanced laparoscopic skills, laparoscopic common bile duct exploration (LCBDE) is technically feasible and increasingly practiced by surgeons worldwide. Traditional practice of suturing the dochotomy with T-tube drainage may be associated with T-tube-related complications. Primary duct closure (PDC) without a T-tube has been proposed as an alternative to T-tube placement (TTD) after LCBDE. The aim of this meta-analysis was to evaluate the safety and effectiveness of PDC when compared to TTD after LCBDE for choledocholithiasis. METHODS: A systematic literature search was performed using PubMed, EMBASE, MEDLINE, Google Scholar, and the Cochrane Central Register of Controlled Trials databases for studies comparing primary duct closure and T-tube drainage. Studies were reviewed for the primary outcome measures: overall postoperative complications, postoperative biliary-specific complications, re-interventions, and postoperative hospital stay. Secondary outcomes assessed were: operating time, median hospital expenses, and general complications. RESULTS: Sixteen studies comparing PDC and TTD qualified for inclusion in our meta-analysis, with a total of 1770 patients. PDC showed significantly better results when compared to TTD in terms of postoperative biliary peritonitis (OR 0.22, 95% CI 0.06-0.76, P = 0.02), operating time (WMD, -22.27, 95% CI -33.26 to -11.28, P < 0.00001), postoperative hospital stay (WMD, -3.22; 95% CI -4.52 to -1.92, P < 0.00001), and median hospital expenses (SMD, -1.37, 95% CI -1.96 to -0.77, P < 0.00001). Postoperative hospital stay was significantly decreased in the primary duct closure with internal biliary drainage (PDC + BD) group when compared to TTD group (WMD, -2.68; 95% CI -3.23 to -2.13, P < 0.00001). CONCLUSIONS: This comprehensive meta-analysis demonstrates that PDC after LCBDE is feasible and associated with fewer complications than TTD. Based on these results, primary duct closure may be considered as the optimal procedure for dochotomy closure after LCBDE.

Successful management of metallic expandable stent-associated tracheal restenosis by Montgomery T-tube insertion.

OBJECTIVE: Tracheal stenosis can be life-threatening and has been seen with an increasing frequency. METHODS: Metallic stent-associated stenosis remains a therapeutic challenge because of difficulty in tracheostomy. RESULTS: Here, we report a case with repeated episodes of restenosis after insertion of metallic stents for benign tracheal stenosis which was successfully managed by Montgomery silicone T-tube placement. CONCLUSION: We further reviewed the literature of reported cases of inappropriate use of metallic stent for benign diseases.

Laparoscopic common bile duct exploration. Lessons learned after 200 cases.

INTRODUCTION: Laparoscopic common bile duct exploration (LCBDE) is a reliable, reproducible and cost-effective treatment for common bile duct stones. Several techniques have been described for choledochotomy closure. AIMS: To present our experience and the lessons learned in more than 200 cases of LCBDE. PATIENTS AND METHODS: Between January 1999 and July 2012, 206 patients with common bile duct stones underwent LCBDE. At the beginning of the series, we performed the closure of the CBD over a T-tube (36 patients), subsequently we favoured closure over an antegrade stent (133 patients) but due to a high incidence of acute pancreatitis in the last 16 patients we have performed primary closure. RESULTS: The 3 closure groups were matched for age and sex. Jaundice was the most frequent presentation. A total of 185 (88,5%) patients underwent choledochotomy whereas in 17 (8,7%) patients the transcystic route was used. The group that underwent choledochotomy had a larger size of stones compared to the transcystic group (9,7 vs 7,6mm). In the stented group we found an 11,6% incidence of pancreatitis and 26,1% of hyperamylasemia. In the primary closure group we found a clear improvement of complications and hospital stay. The increased experience of the surgeon and age (younger than 75) had a positive impact on mortality and morbidity. CONCLUSIONS: Primary closure of the common bile duct after LCBDE seems to be superior to closure over a T tube and stents. The learning curve seems to have a positive impact on the outcomes making it a safe and reproducible technique especially for patients aged under 75.

Comparative efficacy of laparoscopic choledocholithotomy with T-tube insertion vs. primary suture in the management of cholecystolithiasis complicated by choledocholithiasis.

OBJECTIVE: To evaluate the efficacy of laparoscopic choledocholithotomy with either an indwelling T-tube or primary suture in treating cholecystolithiasis complicated by choledocholithiasis. METHODS: We conducted a retrospective analysis of 133 patients with cholecystolithiasis complicated by choledocholithiasis treated at Inner Mongolia Aerospace Medical Baogang Hospital from March 2020 to March 2023. Patients were divided into a control group (laparoscopic choledocholithotomy with T-tube placement) and an observation group (laparoscopic choledocholithotomy with primary suture). We compared general and surgery-related data between groups. Factors correlated with favorable postoperative outcomes were identified using univariate and multivariate logistic regression analyses. RESULTS: The observation group exhibited significantly shorter surgical times, faster intestinal function recovery, reduced postoperative hospital stays, and lower total hospitalization costs compared to the control group (all P < 0.05). No significant differences were observed in postoperative total bilirubin (TBIL), aspartate aminotransferase (AST), or alanine aminotransferase (ALT) levels between the groups (all P > 0.05). Both primary suture technique and the absence of postoperative complications were independent predictors of favorable outcomes. CONCLUSION: Laparoscopic choledocholithotomy with primary suture is associated with shorter operation times, reduced medical costs, decreased hospitalization duration, and quicker gastrointestinal recovery compared to the traditional T-tube approach. This method is safe and feasible, provided clinicians are well-versed in its indications.