Micro-Incision of the Cystic Duct Confluence in Laparoscopic Common Bile Duct Exploration for Elderly Patients with Choledocholithiasis

Abstract

Common bile duct (CBD) stones are common in elderly patients. The laparoscopic transcystic approach with micro-incision of the cystic duct confluence in common bile duct exploration (LTM-CBDE) is a modified laparoscopic transcystic approach. Its safety and efficacy have not been studied in elderly patients with secondary choledocholithiasis. This study evaluates the safety and efficacy of LTM-CBDE in elderly (≥65 years) patients with secondary choledocholithiasis and compares the results with those in younger patients. In this retrospective analysis, 128 patients underwent LTM-CBDE from March 2007 to December 2013. The patients were divided into two groups according to age: the elderly group consisted of 50 patients aged ≥65 years and the younger group consisted of 78 patients aged <65 years. The preoperative morbidity rate, American Society of Anesthesiologists (ASA) score, previous abdominal operations, operation time, postoperative hospital stay, open conversion rate, postoperative complication rate, residual stone rate, recurrence rate and mortality were compared in both groups. The preoperative morbidity (41 vs. 28) and ASA score (2.5 ± 0.7 vs. 1.8 ± 0.6) were higher in the elderly group ( = 0.000, in both groups). No significant differences in previous abdominal operations, operation time, postoperative hospital stay, open conversion rate, postoperative complication rate, residual stone rate, recurrence rate and mortality ( > 0.05) were found between the two groups from March 2007 to December 2013. LTM-CBDE is a safe and effective treatment procedure for elderly patients with secondary choledocholithiasis. For suitable patients, we recommend LTM-CBDE as the treatment of choice.

Dilatation of the Cystic Duct Confluence in Laparoscopic Common Bile Duct Exploration and stone extraction for Patients with Secondary Choledocholithiasis

“…Patients in our study were discharged after a mean postoperative hospital stay of 5.9 days, which is not longer than other reports with mini-incision (mean 8 days) or LCBDE [5,17,18] . Mortality is also in accordance with the findings of other surgical modality [13][14] . Forty-three cases were followed up one year after LTD-CBDE operation (25 patients lost to follow up) and none of them presented with evidence of retained or recurrent CBDS and stenosis of CBD.…”

“…As far as LCBDE is concerned, the problems are mainly related to T-tube placement, such as patient discomfort, biliary peritonitis, T-tube displacement, etc [15][16] . In view of this, some surgeons tried to make full use of the natural cystic duct with micro-incision on CBD or confluence followed by primarily suture [13][14] . Inspired by this, we further speculate: could we use the natural orifices comprising of cystic duct and its confluence at the CBD with no incision?…”

“…The success rate of 91.2% with present method coincides with 88.1% reported in meta-analysis of eleven randomized trials for LCBDE [5] . By using a slightly different approach with a micro-incision at the confluence, Chen et al and Niu et al reported a success rate of 100% [13][14] . The 6 failed patients in our study were associated with anatomical problems, suggesting the importance of a carefully selected surgical strategy.…”

“…T-tube placement presents difficulties in post-operative management [12] . Thus, Chen et al [13] and Niu et al [14] modified transcystic approach with micro-incision of the cystic duct confluence or CBD followed by primary suture without a T-tube. Results had achieved good preliminary effects.…”

Dilatation of the Cystic Duct Confluence in Laparoscopic Common Bile Duct Exploration and stone extraction for Patients with Secondary Choledocholithiasis

“…The success rate of 91.2% with present method coincides with 88.1% reported in meta-analysis of eleven randomized trials for LCBDE [5] . By using a slightly different approach with a micro-incision at the confluence, Chen et al and Niu et al reported a success rate of 100% [13][14] . The operation time reported in the literatures varies widely depending on the surgical method, ranging from 104 to 194 minutes [2,13,17,18] .…”